 So the deaths of despair have generally been defined as self-harm, which includes unintentional and intentional drug overdose deaths, alcohol-related deaths like cirrhosis of the liver, and of course suicide. I'm Shannon Monet. I'm a learner chair of public health promotion and associate professor of sociology in the Maxwell School of Citizenship and Public Affairs at Syracuse University. My research is really interested in social disparities in health as well as geographic variation in a variety of health outcomes. Most recently I've been interested in trying to understand the causes and correlates of disparities from drug, alcohol, and suicide mortalities and related diseases of despair. So one of the things that I think distinguishes these types of diseases and deaths from some other types of mortality, for instance heart disease or stroke or cancer, are that drug, alcohol, and suicide mortality seem to have an underlying link in terms of main drivers of them are things like depression and anxiety and frustration and dislocation from social institutions which include things like not having a job, having a lot of family distress, and not being connected to social institutions. Individual level data on these things are really hard to come by and so oftentimes what we have to do is aggregate up to larger geographic levels like the county level for instance and when you do that what you're doing is using contextual indicators of things like poverty and unemployment to try to predict overall rates in these areas and that of course is flawed because we don't have information on the individual person who died other than their sex, their race, their age so we don't know about their whole life course and the extent to which that influenced the way in which they died or influenced their first initiation of drug misuse or alcohol misuse or when the mental health problem started to develop. One of the things that my research really shows is that drug, alcohol, and suicide mortality are very geographically dispersed, range pretty substantially across the country from really low rates to really high rates. In general the most salient predictors of county level high rates of drug, alcohol, and suicide mortality is not only current economic distress, the conditions that are present right now like poverty and unemployment and disability, but a more of a long-term transition into economic distress. So places that were once economically stable and even prosperous in the 1980s because of strong manufacturing industry because of unionization, those are the places that have seen the most significant economic decline over the past three decades or so and that decline matters just as much as kind of chronic long-term economic distress. So at the absolute level poor economies really matter, lack of opportunity really matters, but so does change as sort of a shock into that labor market. The other thing is that the media often use the sentiment that addiction doesn't discriminate and of course that's true, anyone can become addicted, but it's also true that drug overdose mortality rates are much higher in some geographic areas than others and one of the problems that can arise when we say addiction doesn't discriminate is that it assumes that we should just distribute resources equally and oftentimes the places that are dealing with the largest consequences get undercut because of that. On election night when the returns were coming in what I noticed from the map is that the places where Donald Trump was winning, especially places where he wasn't predicted to win, that map looked an awful lot like my drug overdose mortality map and so I purchased some data just for Michigan at the time and ran a basic correlation and noticed that counties where Trump overperformed the most relative to how the previous Republican candidate did those places had the highest drug alcohol and suicide mortality rates and then I purchased the rest of the national data and expanded that from there and found that he overperformed the most in counties where drug alcohol and suicide mortality rates were high, but even more than that he performed the most in places that were distressed upon all kinds of indicators so not just mortality but also economic distress, family distress, places for instance that have high rates of divorce were also more likely to be places where Trump overperformed and places that have less social capital so opportunities for building social relationships, organizations that people can be involved in all of these factors were partial explanatory indicators of why Trump overperformed in the places that he did. I'm from upstate New York and when people think of New York they often think about it as a really liberal state. The reality is when you go north of say Westchester County if you get out of the city at all the level of conservative increases as the further north that you go so I'm from a rural town, a very conservative town and a lot of people in that town voted for Trump and they were very enthusiastic about it and one of the things that they know is that they feel like the Democratic Party has really helped the poor people the most and kind of forgotten working class folks in small towns and these are people who are working they're working in jobs like diners, their mechanics, their bus drivers, some of them are small business owners who have seen the profits significantly decline because of increased regulation that might make sense for corporations but doesn't make as much financial sense for small businesses. What they're seeing is that the best and the brightest leave the small town to go off to college and never come back and that leaves a larger and larger concentration after multiple generations of the people who are least resource and most vulnerable and those people tend to not be working and people in my town see this and they get frustrated because it's a small town you know everybody so if there's one grocery store to go to and you see somebody using their snack benefits on food that you can't afford to buy yourself then that is a big frustration for people who live in my town. They're also increasingly saying that young people here don't want to work that there are jobs available but they can't find people to take those jobs and that you know frustrates people in my hometown that are working class and feel like they're just breaking their back to make ends meet and that so many resources appear to be going to the low-income people in that town. They're also seeing increases in drug overdoses and police officers are frustrated because they're spending a lot of their time having to revive people and carry Narcan and it limits their ability to call on other problems that arise because if their time is so taken by these drug overdoses and it's a resource that isn't available for other kinds of responses so ultimately people in my town express a lot of frustration with political elites with academic elites they watch different news than I watch they read different things that than I read and the message that they're getting from the sources that they're consuming media from are that America is in pretty dire straits things don't look to be going very well and it's the Democrats fault and what we really need is someone to come in here and just blow everything up. One of the big debates is whether this is really about economic distress or racial resentment and I don't think that those are competing explanations so in places that the economy declines those places are really vulnerable and ripe to internalizing messages of racial resentment and sociologists have been talking about this for a long time when the economy is going well overt expressions of racism decline and when the economy is doing poorly and they're and it feels like it's a zero-sum game and there's a limited number of resources available then racial resentment tends to increase the other issue is that we have to remember that Donald Trump lost the popular vote by nearly three million votes so not only did Hillary Clinton receive more more votes than Trump but Trump actually underperformed relative to Mitt Romney he received a lower percentage of the vote share in 2016 compared to what Romney received in 2012 but because our system is based on the Electoral College what that means is that some states matter more when it comes to the election outcome and in this particular case Pennsylvania, Wisconsin and Michigan were the three game changers Trump won those three states by a combined 77,000 votes spread across three states if we just break it down to Pennsylvania for instance he won Pennsylvania by 26,000 votes and over 60 percent of his victory share there of those 22,000 votes came from one county LaZern County which is the home to Wilkes-Barre now Wilkes-Barre is one of these places that has experienced significant economic decline over the past 30 years the income there meeting hustled income in LaZern County is now lower than it was in 1980 quarter of prime age men and women are not working they're either unemployed or they're out of the labor force all together and so when we start actually pinpointing the regions where Trump won where he wasn't predicted to win these are the game changer regions the swing places those are places that have experienced significant economic decline and that's not to say that other parts of the country didn't have large concentrations of highly educated and affluent people also voting for Trump but we need to distinguish between whether our question is who voted for Trump versus what was the difference maker for Trump winning this election in the primaries Hillary Clinton won southern states won western states she won the states that a democrat likely would have won in the national election anyway okay sanders won the primary in states in the industrial midwest that then trump ended up winning in the national election so the question is then for democrats going forward is it more important that your candidate win the so-called swing states versus the majority of states because right now the system is based on whoever gets the most delegates but whoever gets the most delegates might end up being irrelevant in the national election if increasingly our elections come down to a handful of states a lot of people in the media and academics in the public were surprised at the outcome of this last election and and there have been all kinds of explanations of trying to understand why what happened and underlying a lot of these explanations is that this was just an all of a sudden thing that oh my gosh our country just changed overnight what the heck went wrong when the reality is the cues have been there for a long time that since the 1980s the overwhelming majority of places in this country have not received any of the economic gain increasingly more and more income and wealth are filtering into the hands of very very smaller groups so that we have a massive income and wealth inequality problem in this country and that didn't happen overnight so well we have devalued trade skills we've devalued work in manufacturing and increased the value that we place on technology and finance large swaths of this country have been left behind it's been building for the last three decades and it's not just about the economics it's not just about the paycheck we used to be a nation of producers we used to actually make things and now the highest paid jobs are people who click a button on a keyboard and move money from one balance to another balance and so increasingly people in the US and even internationally are feeling disconnected from their labor they feel like their their work is devalued underappreciated it's not meaningful and that meaning has influence for the rest of of their lives it affects mental health physical health it affects family relationships and so all of this decline together this kind of package or basket of decline the chickens are finally coming home to roost on this and and people are reacting with their voting behavior now i've always been interested in trying to understand social and geographic disparities in a wide range of health outcomes and i always said i wasn't necessarily interested in what the health outcome was i was just interested in the things that led to inequality but then when i started to try to understand what was going on with substance misuse disparities and i started to see these tight connections to this sense of anime and aimlessness and anxiety and frustration and that all made sense given that the economy has been declining in these places for a long time and and so i thought you know what are the common the common binds here and that's what really got me fascinated and interested when you see these problems affecting rural areas that you know drugs have always been an issue but you know heroin kind of came along and is now decimating small cities and rural areas that just don't have the resources to combat it and you know i think i just wanted to try to understand why this is happening so the majority of resources thus far have gone into trying to increase access to treatment and naloxone narcan brand name which is the antidote to an opioid overdose and tremendous amount of resources have been spent on these things and certainly treatment is important in increasing access to narcan is important but we're not going to narcan our way out of this because the problem is bigger than opioids it's bigger than drugs the problem is a result of long-term economic decline and social decline our relationships have disappeared we have traded space and houses which have continued to get bigger for friendship which has continued to decline okay we've we've given up connection for stuff in the united states and so what that means is that in order to solve the opioid problem and all the connected problems with it is we really have to get down to the core foundation of those problems and that has to do with people feeling like there is no meaning in their life and that things are worse off than they were in the past