Thursday, July 5, 2018

Suicide in Rural America

With the tragic celebrity suicides of Kate Spade and Anthony Bourdain, the subject of suicide is again part of the national dialogue. It’s a shame that it takes a celebrity victim (such as from suicide or a drug overdose) to finally call our attention to serious issues like this. Maybe better late than never?

At about the same time that these suicides occurred, the Center for Disease Control and Prevention (CDC) released a study showing that the US suicide rate increased about 25% from 1999 to 2016. This in itself is pretty disturbing. But while the 25% is a lot, it’s much worse than it looks!  For you see, the 25% is just an average across the country.  While some states were lower than the 25% figure, some were higher - much higher. The map below shows a number of states in the 38-58% increase range. The dubious champions were North Dakota (57.6%) followed by New Hampshire and Vermont (48%) and South Dakota close behind (44.5%). There were also a significant number in the 31-37% range. Although Nevada is shown as a slight decrease, its suicide rate was already high to begin with.

There were obviously a number of causes for the 25% overall increase. But with some of the states far above the overall average, those causes were a whole lot worse in those states.  But why? The answers would explain a lot.

So what do the states with the highest suicide rate increase have in common? It looks like these are states with a lot of rural areas.  Furthermore, the states with the worst numbers are not only rural but very sparsely settled. Indeed, the rural areas have fallen on especially hard times. And that is the subject to be investigated here.

Our lifestyles of increasing social isolation are a problem in many places. It is generally agreed that increasing social isolation can lead to trouble in the form of depression and at its worst can lead to suicide. Where people used to get together in groups to interact face to face, communication is now much more through Emails and text messages between our computers and smartphones.  Who hasn’t seen a group of teenagers gather together in a group but instead of talking, will bury their faces in their smartphones texting each other.

Sparsely populated areas will always face special challenges from social isolation whether it’s in the US or elsewhere.  However, there are trends in the US that are making things worse.  With jobs such as in mining, paper mills, and textiles disappearing, new generations of young educated people are leaving the rural areas for the cities which have many more career opportunities, The result is a hollowed out population of mostly elderly who in many cases have difficulty getting around.

The loss of various industries can lead to troubles that are greater than just job loss. Losing one’s livelihood can be crushing, not just financially but from a mental health standpoint. For all too many of us, our jobs are a part of our identity and a way we contribute to society. Once thrown on the proverbial scrap heap, it’s all too easy to conclude we are worthless which can lead to depression (which from personal experience I know all too well) and perhaps ultimately, suicide if help doesn’t come along in time.

But while these losses due to industries moving are fairly well known, less well known is that American farmers are killing themselves in record numbers.  In some states, the farmer suicide rate is even higher than the rate for veterans.

In fairness, farmer suicides are not unique to America.

The US farmer suicide crisis echoes a much larger farmer suicide crisis happening globally: an Australian farmer dies by suicide every four days; in the UK, one farmer a week takes his or her own life; in France, one farmer dies by suicide every two days; in India, more than 270,000 farmers have died by suicide since 1995.

It is well established that severe financial stress can be a trigger to suicide. Farmers’ financial well being often depends on factors beyond their control such as weather and politics.  They have had struggles for years from the reduced prices for the commodities that they sell. Now this situation has been greatly exacerbated by a deliberate decision by the Trump administration to ignite a trade war.

Since April, duties the U.S. has levied on goods from China, Mexico, Canada and the European Union have sparked retaliatory tariffs and trade threats, targeting American farm goods from pork to cheese to apples.
Disquiet among farmers grew in June as crop prices fell thanks to benevolent U.S. weather and additional duties expected from China on products like soybeans, for which it is the U.S.’s top customer. The total value of this year’s U.S. corn, soybean and wheat crops dropped about $13 billion, or 10%, in June, said Chris Hurt, an agricultural economist at Purdue University. On Monday, U.S. soybean prices continued their downward spiral, heading toward the lowest level in a decade.
And once these various countries find other sources for their agricultural food needs these markets may be lost for the foreseeable future.  Mental health resources can help these farmers to cope with the possibility of economic ruin. But...

Mental health resources while sometimes strained in the city can be next to unavailable in rural outlying areas.  And for those without insurance, it’s even worse. And with the opioid epidemic spreading to rural America, sources for treating addiction are often few and far between.

Medical and dental care are problematic as well. Doctors are not attracted to impoverished areas.  Rural America has too few dentists along with few jobs to create paying patients. And as icing on the cake, rural states especially out west under Republican control do not have access to Medicaid because their governors rejected this part of Obamacare.

There have been a number of philanthropic efforts to provide medical and dental care to rural America. Most notable is Remote Area Medical which was founded by Stan Brock to take care of medical needs in the Third World. But after he saw the sorry shape that rural America was in, he decided America was where he was needed most. But he can’t be everywhere. Getting sick and not hot having access to medical care can put a terrible strain on a person.

So can poverty. In the cities, help is often available from organizations that can rely on donations from relatively affluent people. In a rural town where often everybody is poor there is no such help.

And finally, rural areas in general but especially the states in the sparsely populated heartland have a culture where gun ownership is almost universal.  While we all mourn the homicides that often command so much of the news, a lot more US gun deaths are due to suicides rather than homicides.

In the United States, access to firearms is associated with an increased risk of completed suicide. A 1992 case-control study in the New England Journal of Medicine showed an association between estimated household firearm ownership and suicide rates, finding that individuals living in a home where firearms are present are more likely to commit suicide than those individuals who do not own firearms, by a factor of 3 or 4.

So while all of the social isolation and other social problems in rural America may drive people to contemplate suicide, a gun as a handy and lethal way to accomplish the act makes it more likely to happen.
David Hemenway, professor of health policy at Harvard University's School of Public Health, and director of the Harvard Injury Control Research Center and the Harvard Youth Violence Prevention Center, stated:
Differences in overall suicide rates across cities, states and regions in the United States are best explained not by differences in mental health, suicide ideation, or even suicide attempts, but by availability of firearms. Many suicides are impulsive, and the urge to die fades away. Firearms are a swift and lethal method of suicide with a high case-fatality rate.
So we must now ask the question - can anything be done about all of this?  In my humble opinion there is good news and bad news. The good news is that there are solutions to try and address this tragic situation.  The bad news is that at least most of the solutions require money - mainly federal money since many of these states are already strained for resources because of their ideological addiction to tax cuts.  Furthermore, these admittedly liberal solutions would most likely be treated with scorn by these people who need help the most. But nothing is stopping me from making suggestions.

The quickest way to stop the bleeding would be for America to provide universal health coverage, including dental and mental health - just like in the rest of the industrialized world. Philanthropic efforts such as the aforementioned Remote Area Medical along with The Health Wagon are greatly appreciated but are far from a solution. Indeed, many of the patients seen have suffered irreversible damage to their health, A number of them were too far gone to save. In spite of the right-wing rhetoric on Obamacare "death panels" the true death panels are the Republican governors of states who refused the Medicaid expansion part of Obamacare for their citizens for reasons that amount to little more than spite. In addition, the lack of patients with insurance to pay for medical services has led to the closing of hospitals in a number of rural communities, thus depriving them of emergency room care within practical distances. I know - single-payer universal health insurance is little more than a liberal pipe dream with Republicans controlling all the levers of power. But extending the Medicaid expansion to the states without it would be a great help in the meantime - like what recently happened in Virginia.

Help in creating and expanding community centers in small rural towns would help to fight the loneliness often encountered there. Having a place for people to gather in places like this would promote more of a sense of belonging which would in turn discourage suicide. We finance senior community centers in the city where I live.  Why not do the same for rural America?

As for bettering the economic prospects for rural America, there are no easy answers. Attracting prospective employers to a place that has poor medical care and indeed, might not even have a hospital would appear to be hopeless. But our president instilling false hope in the return of lost coal mining jobs is little more than cruel and manipulative. On the other hand, not all industries are contracting. For example, there are more jobs to be had in renewable sources of energy such as solar and wind which are better suited for remote areas. Although the Great Plains has by far the most abundant wind supply, new technology in the way of taller wind turbines may indeed make wind power viable in all 50 states!  The Tennessee Valley Authority was born in 1933 under FDR to provide economic relief to parts of Appalachia, primarily by hydroelectric power.  It is encouraging that they are at least slowly starting to branch out into solar and wind power.

Another issue that is near and dear to liberals like myself is gun control. Just focusing on the area of suicide for now, a study has shown that background checks and waiting periods for gun purchases are associated with lower rates of suicide. Of course not all suicides are by guns. But it stands to reason that not making guns so readily available would save some lives.

Finally, it can be instructive to study countries that have a lower suicide rate to see what they do differently.  Let’s take three bordering countries - Canada, the United States, and Mexico. According to this chart from the World Population Review listing suicides per 100,000, the US ranked 43rd with 14.3 suicides per 100k with Canada close behind at 46th with 12.3 suicides per 100k. Then there is Mexico coming in at 143rd place with only 5 suicides per 100k. What makes this even more remarkable is the crushing amount of extreme poverty in Mexico where according to Wikipedia some 35% of Mexico’s population is living on less than $5.50 a day (compared to only 1 or 2% in the other 2 countries). Clearly financial distress can lead to suicide but why is Mexico an exception here? Here’s a likely explanation: Mexico is known for its close family culture.

Every culture has a unique set of values, traditions and norms. The general culture of Mexican families has a strong foundation in unity. As with any culture, family life is as much individualistic as it is communal.

So while many Mexicans suffer through the same problems coping with poverty, family members have their back so they don’t have to suffer alone unlike many Americans especially in those remote rural locations.

Yes, we do need to invest the resources to fix our shattered safety net. But we must also remember that as humans we have a need to connect to others and to belong. This means reaching out to each other and remembering that we are all in this together. Yes, there will still be suffering. But unlike some others who were not as fortunate, we will want to live to tell about it!