A cemetery in a small town in Virginia. (Joel Achenbach/The Washington Post)

By now I hope you’ve had a chance to read the first two installments of the new Washington Post series Unnatural Causes: Sick and Dying in Small-Town America. We’re exploring rising death rates among midlife white Americans, particularly women. The first two stories come at the subject from opposite directions: The first, by Eli Saslow, looks at one family. The second is a data analysis that looks at the whole country.

A lot of reporting is still to be done on this — it’s a sprawling and complicated subject. It’s not easy to disentangle factors such as gender, race, income, education and geography. Statistics can be enigmatic. They can enlighten but they can also mislead. So we have tried to be rigorous and cautious in reporting what we’ve found in the data. What we discovered, in our second story, is a very distinct divide between urban and rural death rates among whites (“rural” used expansively because it includes small cities — basically everything outside of a major metropolitan area). This is consistent with other research and with what anecdotally many people have seen in recent years: greater poverty, disability and hopelessness in white working-class communities and in small-town America.

So what do we do about it? Our readers have ideas, and I’m going to post some of their comments below. As you’d expect, there are great differences in opinion about what is driving this, and whether these dying folks are victims of larger societal forces or of their own bad decisions. Some of the comments echo the controversial Kevin Williamson essay that recently appeared in National Review. But what I find most interesting are the personal stories.

Here’s one:

It’s one thing … if all of us have to bear the short, hard, bitter life together. It’s another if we are working harder than ever, not being rewarded for it, and we are constantly being shown how a tiny percentage at the top of society is reaping the rewards of our hard work. I have a simple life, despite a graduate degree. For years before Obamacare, I went without health insurance involuntarily. I drive a 20-year-old car. I live in a humble neighborhood. I have much to be thankful for, but it’s hard not to be resentful of CEOs that earn literally thousands of times as much as I do while doing less productive work. This enormous disparity in distribution of resources is really quite new in our society.

Here’s an excerpt of another:

Four decades ago my wife and I escaped the rust belt for Silicon Valley. When I return I am appalled at the physical condition of family, friends and neighbors. Even the healthiest of those with college educations look 10-15 years older than my neighbors here. Most look much worse. It seems nearly all are carrying an extra 100+ pounds, eating too much sugar, processed snack foods and useless calories.

People there still smoke, and smoke heavily. Their kids, now adults, smoke. Curiously, those who mostly smoke marijuana look healthier than those who are heavy drinkers.

The overriding impression is one of hopelessness masked by consumerism. The 7% GDP shift in incomes from 40 million working people to the top 1/100th of 1% literally has taken its toll on those in the lower middle. They borrowed on credit cards to buy more stuff at Walmart, and then couldn’t pay the bills, lost the house and filed bankruptcy.

I saw two in-laws, mother and daughter, who worked at Walmart for a period that literally accelerated their decline into near-poverty. Even with both parents and both teens working they barely could keep the very used cars running and the rent paid.

Here’s one from Oregon:

I moved to a rural area in Oregon 3 years ago. This area has many challenges related to isolation and lack of infrastructure. Our economy is having difficulty transitioning from forestry and milling to a more tourism based economy. We still have fishing, but closures and variable harvests create challenges for the folks in the fishing industry. We do have some local farmers adding revenue by selling more finished products locally. State mandated zoning restrictions and lack of adequate commercial zoning limit business opportunity. Basic health care is generally available, but if you need a specialist, you will need transportation and time to drive 100 miles or so to the nearest cities. No dialysis, dermatologists or oncologists here. Our area also lacks resources for treatment of addiction and psychiatric conditions. We seem to have a high rate of methamphetamine use and a growing problem with heroin to accompany the lack of resources to treat addiction. As I think about it, we do seem to have more deaths of middle aged residents from illness than I recall seeing in the city. Thanks for the interesting piece, WaPo.

(Yes, kudos are appreciated!)

And now the reaction from Hungary:

Having spent the last 15 years in Europe I’ve come to see how some elements of American life that have become normalized are profoundly dysfunctional but not recognized as such by too many. Consider funding for schools, which is tied to property taxes: a sure fire way to maintain inequality and prevent social mobility. Or health care. I have raised three children in Hungary and can say unequivocally that the single payer system here is better than the American system in most respects. In terms of public health it is far better. And it is virtually unheard of to put people on opioids or anti-depressants. Doctors are much more likely to recommend lifestyle changes, the state pays for extended rehab at spas and so forth. It’s cheaper and works better. When I visit the U.S. I’m just astounded by what and how much people eat. It’s grotesque and most of what’s in supermarkets can’t be described as food. Hungarians and most Europeans eat most of their meals with family, and most food is still home cooked. It makes all the difference. Towns and cities are people friendly and even less affluent people spend time, often daily, relaxing with friends at cafes. Everyone takes at least a month off — usually at one go — during the summer. There is way, way less stress for most people. There may be costs in terms of economic efficiency, but so what? Life is better, and this is true for all countries here, including poorer ones like Hungary.

Another reader gives us the view from Colorado:

When I first started working here in Vail Colorado I moved to Leadville. But it’s a dying town full of drunks and drug addicts. I met people who literally had not had a job in a decade, and many who made a living mowing lawns and picking up trash. The people looked like hippies but they had some decidedly right wing views, along with paranoia about chem trails and other government conspiracies. Their Congressman is a right wing kook who never speaks to any of them. The chief of police got arrested for drunk driving and then got indicted on 14 felony counts. Everyone in the town smokes. I think this is the world the article speaks of.

And this one from the UP in Michigan:

Please visit the Keweenaw Peninsula in the Upper Peninsula of Michigan. The area is not culturally barren, not anti-science, and very few religious zealots of any flavor. There are druggies, and some people drink far too much, but we also have very high unemployment. Things were not always this way. One hundred years ago, this region had well over 1 million people. Anyone could get a job that paid decent. The mines closed for good in the late 1960s, early 70s and it has been all down hill since then. Just like all the other mining areas.

Most people live as simply as possible and eat as healthy as they can afford. Often they grow their own food and live off the land as much as possible. It is always easier to make such sweeping judgments when one lives in a concrete jungle.

And then there’s this very powerful comment from a woman who doesn’t give her location:

I’m a 56 year old white woman. A working class white woman with a job with a salary that very rarely increases. I struggle. This string of comments makes me want to commit suicide. Most of you have no idea what you are talking about except for your own views and pushing your own agenda. Our government has failed us. This has been going on for MANY years. Lost hope is the cause. If you don’t understand this, then you are one of the lucky ones. Yes luck. We aren’t all lazy, drug and alcohol addicted worthless human beings. We are molded by environment and family history, race and education. Loss of compassion for our fellow man, narcissism and greed are what this country is about today. Go ahead you nasty jerks. Tell me that my politics are wrong, or that if I don’t like it to go ahead and kill myself. You know that’s what you’re thinking. Prove my point.

Further Reading:

Where living poor means dying young