The death rate for white Americans aged 45 to 54 has risen sharply since 1999, but Montana officials wrestle to explain why the state has the highest rate of suicide in the US at nearly twice the national average – and it’s rising
Kevin Lowney lies awake some nights wondering if he should kill himself.
“I am in such pain every night, suicide has on a regular basis crossed my mind just simply to ease the pain. If I did not have responsibilities, especially for my youngest daughter who has problems,” he said.
The 56-year-old former salesman’s struggle with chronic pain is bound up with an array of other issues – medical debts, impoverishment and the prospect of a bleak retirement – contributing to growing numbers of suicides in the US and helping drive a sharp and unusual increase in the mortality rate for middle-aged white Americans in recent years alongside premature deaths from alcohol and drugs.
A study released late last year by two Princeton academics, Anne Case and Angus Deaton, who won the 2014 Nobel prize for economics, revealed that the death rate for white Americans aged 45 to 54 has risen sharply since 1999 after declining for decades. The increase, by 20% over the 14 years to 2013, represents about half a million lives cut short.
The uptick in the mortality rate is unique to that age and racial group. Death rates for African Americans of a similar age remain notably higher but continue to fall.
Neither was the increase seen in other developed countries. In the UK, the mortality rate for middle-aged people dropped by one third over the same period.
“This change reversed decades of progress in mortality and was unique to the United States; no other rich country saw a similar turnaround,” the study said.
Deaths from poisonings by drugs or alcohol have risen dramatically to push lung cancer into second place as the major killer with a sharp increase in suicides now a close third.
‘I was a very hard-working American. Overly hard-working American. This is what brought down my health,’ Kevin Lowney said. Photograph: Walter Hinick for the Guardian
Lowney lives in Butte, Montana, where local officials see the Princeton study’s findings reflected in their community but struggle to explain them. The state has the highest rate of suicide in the US at nearly twice the national average and rising – up 7.3% in 2014. Those most likely to kill themselves are 45 to 65 years old.
“What’s been lacking in our town is an explanation for why this demographic in particular has been dying by suicide,” said Karen Sullivan, health director for Butte and the surrounding county, Silver Bow. “We want to take a look at what we’ve got going on in Butte. Is it economic in nature? Is it middle-aged white people discontented with where they landed in life? Is it isolation? A lack of a social network? Is it drug and alcohol issues? What do we have going on?”
Other officials see a number of interconnected forces at work and the rising rate of middle-aged deaths as indicative of crisis wider than those who kill themselves.
Growing economic inequality and increasing financial struggles are intertwined with other issues such as health and addiction. Some people living on low incomes hesitate to go to the doctor even if they have medical insurance because of the cost of out-of-pocket expenses. Chronic conditions can go untreated and become debilitating.
Pain is a driver of alcohol abuse and addiction to opioid painkillers, which in turn is feeding a growing heroin epidemic in the US. Stress and mental health issues are sometimes driven by constant worries about money and fear for the future as growing numbers of Americans look into a financial abyss at retirement.
What has changed?
Karl Rosston, Montana’s suicide prevention coordinator, said there are a number of constants that contribute to a historically high suicide rate throughout the Rocky Mountain region from social isolation to the availability of guns and a reluctance to seek mental health care.
But all of those are longstanding issues in Montana. So what’s changed to drive up the rate of people taking their own lives in recent years?
“Probably the biggest reason is socio-economic. We have about 150,000 people in our state that don’t have access to any type of healthcare, which is a major issue. We have a lot of people living in poverty. Wages are not going up at the same pace as rising health costs, rising cost of living and inflation,” Rosston said.
“Definitely you see a lot of people that all of a sudden they hit 45 or 50 and they don’t see retirement as a bonus. They see something that they’re going to have struggle with and they’re not going to be able to retire.”
Sullivan sees that as tied up with “the expectation that as a middle-aged white person you would outdo your parents economically and socially, and that didn’t occur”.
Lowney is typical of those baby boomers who have seen expectations dashed. His grandfather immigrated from Ireland to work as a miner when Butte was renowned as “the richest hill on earth” for the copper beneath. His father, Jerry, was raised in impoverished conditions but by the 1950s had moved up the social scale working as a civil engineer in a Butte hospital. He owned a house and a car. He had eight children, of which Kevin was the youngest, and retired on a comfortable pension without debt.
Kevin Lowney has not been so fortunate. He has never owned a house and is drowning in medical debt attributed to hospital costs and doctors office visits to treat his failing health.
“I was a very hard-working American. Overly hard-working American. This is what brought down my health,” he said.
Lowney studied to be a mining engineer but Butte’s copper mines shut down in the 1980s, taking with them well paid union jobs. The mine was bought out and reopened a few years but with a smaller, non-unionised workforce on an income dependent on the price of copper. By then Lowney had switched to a business degree and landed a job in California as a salesman for a food delivery company.
Lowney returned to Butte in 2002 and went to work for Walmart as a cashier. His health continued to deteriorate.
Rising healthcare costs
“In one year I had surgery on both hands, bladder cancer surgery, hernia surgery. My heart was starting to fail. I developed diabetes. High blood pressure. Enormous stress,” he said.
Lowney had health insurance but still ran up tens of thousands of dollars in medical bills. In 2007 he applied for a disability grant. It took five years to be approved, during which time he relied on food stamps and other small grants he was entitled to as a single parent raising his teenage daughter.
When the disability allowance came through in 2012, payments were backdated to the date of his application. But almost all of that lump sum immediately went to clear some of his outstanding medical bills. That still left him more than $40,000 in debt to doctors and hospitals.
“I have never drinked. I’ve never smoked. I’m a very strong Catholic and I practice those values. No way is this from any immorality on my part,” he said. “Here I am, I’ve worked hard all my life, put myself through college, raised three kids, been a single parent at different times in my life. Now I’m bankrupt. Not only bankrupt but with a remaining huge debt.”
Except Lowney isn’t legally bankrupt because he says he can’t afford the $1,200 fee to file the paperwork. His only income is the $1,481 month disability grant. He lives in sparsely furnished two-storey public housing. On the wall next to the kitchen door is a picture of Lowney with former president Jimmy Carter when the pair were working as volunteer house builders for Habitat for Humanity in Mexico.
“We put up 100 homes in Tijuana in a one-week blitz,” he said. “The irony is I’m now living in public housing myself. Which, by the way, I’m very thankful for.”
Much of his income still goes to pay for medical treatment, including the two trays on his living room table of an array of pills to treat his various conditions.
“I still pay at least $300 a month in medications,” he said. On top of that there are bills for regular visits to the hospital. Some months, he relies on the local food bank to feed himself.
In searching for explanations for why the US is alone among developing countries in grappling with a rising death rate among its middle-aged white population, Lowney contrasts his situation with a cousin, a fisherman in Ireland who was injured in a work accident at sea and spent a year in hospital.
“He told me it cost him 39 euros. That’s all because of the health system they have in Ireland,” he said.
Lowney ran up most of his debts before Barack Obama’s healthcare reforms. They have been a big leap forward for many Americans by, among other things, preventing insurance companies from cutting people off mid-treatment or capping payments for expensive medications, such as for cancer.
But even with subsidized rates for low-income families, a trip to the doctor can still prove expensive because most insurance policies require holders to pay the first few thousand dollars each year before coverage kicks in.
That has put many people in the position of paying for insurance but being unable to afford to go to the doctor.
According to the Butte-Silver Bow Community Health Needs Assessment for 2014 23% of people in Montana have no health insurance.
But the report said that even among those with insurance, nearly 40% faced obstacles to receiving needed healthcare. About one-third said they could not afford the cost of the doctor or prescription. Nearly 8% said they lacked transport to get to a clinic. More than 11% said they skipped or reduced prescription doses in order to save money.
Kristen Ryan is among them. She works with children with disabilities in Butte. Her husband is a maintenance engineer at an elementary school but has two additional part-time jobs, including bar shifts, to bring in extra cash.
“It’s to keep our head above water, to keep our kids in clothes and hot lunches. We make too much money to get help but it still is difficult,” she said.
The couple owns a small house Ryan bought when she was single but it only has two bedrooms to house four children and they cannot afford to buy a bigger place.
Ryan and her husband both have health insurance through their jobs but they hesitate to go to the doctor because they have to meet the first $5,000 of treatment costs.
“It has to be something pretty significant for me to go and the same for my husband,” she said. “I see that in my husband where his back will hurt or he’s got a funky foot and sometimes he’s in a lot of pain but he won’t go because he knows that it’s going to end up costing a lot of money just to see the doctor.”
Chronic pain and suicide
The Princeton study and Rosston both identified chronic pain as a big driver of suicide among middle-aged people.
“The typical death certificate that I often read is a typical 55-year-old male who is having chronic pain issues in his back and is not being treated,” he said. “We know nationally that about 30% of the people who die by suicide have issues of chronic pain or chronic illness. We saw even higher numbers in Montana.”
The increase in chronic pain has been tied to the surge in abuse of opioids such as Oxycontin, which have taken hold across the United States. That has contributed to a sharp rise in unintentional poisonings from drugs and alcohol which have risen by about 160% nationally since 1999. Montana has 82 painkiller prescriptions for every 100 people.
Case and Deaton say that “addictions are hard to treat and pain is hard to control, so those currently in midlife may be a ‘lost generation’ whose future is less bright than those who preceded them”.
Sullivan thinks it is less bright for other reasons. She said for many the prospect of retirement is a fresh crisis.
Lowney had to cash in his small pension of $17,500 to pay medical bills. Ryan sees no prospect of retiring.
“My job cut the employer contribution to my pension a couple of years ago. I prefer not to think about that because I know I don’t have anything. It’s very small. It’s not going to be enough to live on,” she said. “I think public housing or something like that might be in our future as we get older because I don’t know that we’re going to be able to do it on our own.
“We owe my mother-in-law quite a bit of money because sometimes more goes out than comes in. You don’t expect to have to borrow from your parents at this age. You would hope that they would be able to borrow from you if they needed to but that’s just not the way that it’s turned out.”
The Princeton study also notes that a higher proportion of middle-aged suicides are among people who have less than a university education, suggesting they are more likely to be in lower income jobs and more severely affected by growing economic inequality. Rosston sees that in Montana too.
“I actually review every single suicide that occurs in the state and we see that a very high percentage – about 80% – had less than a college degree. That may correlate with the type of jobs, the labour jobs, that they had because with only a high school education or maybe just a little bit of college you’re more likely to be in those labour intensive jobs,” he said.
Tracy Thompson heads the Laborers’ International Union of North America in Butte. She used to be a construction worker and then held a job at a pulp mill in Missoula, to the west of Butte, until it shut down in 2009.
“We lost four people to suicide when they closed their doors. These were individuals making $50,000 or $60,000 a year, maybe more. All of a sudden they’re forced into early retirement or to find employment elsewhere. One guy had worked there for 30 years. We were all shocked he took his life,” she said. “You see it all around. You see a guy dies at 53. What did he die of?”
According to the Butte-Silver Bow Community Health Needs Assessment for 2014, more than one-third of residents show symptoms of chronic depression.
“I grapple with depression,” said Ryan. “I take an anti-depressant. I find my situation very stressful. I find that I have trouble sleeping. I have to tell myself not to think about it so I can go to sleep. It’s hard not to be able to do for your kids what you want to be able to do.
“I’ve heard that the majority of Americans are afraid of even a $500 emergency. They’re one broken refrigerator away from not being able to make it. That’s us.”
That may go some way to explain the differing middle aged death rate with other developed countries that have extensive welfare systems, free or cheap health care and greater support for pensioners. The proportion of US pensioners living in poverty is more than double that in Germany and nearly six times that of France. Few western Europeans are fearful of losing their homes to pay medical bills.
Sullivan also thinks there may be something else unusually American at work.
“I’ve watched white males rule this country from the beginning. The power that this traditional white male used to have is decreasing. We’ve evolved and white males aren’t necessarily at the root of power anymore. Everything from the Oregon military takeover to the abuse people have hurled at our president, I think a lot of that is at play,” she said.
African Americans on the other hand have long struggled against inequality and have generally held fewer assumptions about social advancement, which may explain why the same increases in suicides and drug and alcohol deaths have not been seen among middle aged black people.
Rosston said that whatever the causes, the increased numbers of suicides reflects a mental health crisis that is not being addressed in part because of a lack of professionals but also because of a reluctance to seek their help.
“We have a very high shortage of mental health professionals in our state, specifically psychiatrists. About 80% of the people who take psychotropic medication in Montana have never even spoken to a psychiatrist,” he said. “Also, there’s a stigma when it comes to mental illness. We have that kinda cowboy mentality, frontier mentality of taking care of your own, and people see depression as a weakness.
“The words I often see when I review suicides is that the person thought they were a burden. That they weren’t serving a purpose anymore or they’re tired of dealing with things. When you feel that way, you’re not going to ask for help.”
• In the US, the National Suicide Prevention Hotline is 1-800-273-8255. In the UK, the Samaritans can be contacted on 116 123. In Australia, the crisis support service Lifeline is on 13 11 14.
Chris McGreal in Butte, Montana