After decades of progress, life expectancy — long regarded as a singular benchmark of a nation’s success — peaked in 2014 at 78.9 years, then drifted downward even before the coronavirus pandemic. Among wealthy countries, the United States, in recent decades, went from the middle of the pack to being an outlier. And it continues to fall further and further behind. Chronic diseases are the greatest threat, killing far more people between 35 and 64 annually, but where and why?

Even during the pandemic, heart disease and cancer remained the leading causes of death for people aged 35 to 64. And many other conditions — private tragedies that unfold in tens of millions of U.S. households — have become more common, including diabetes and liver disease. These chronic ailments are the primary reason American life expectancy has been poor compared with other nations.

Deaths of adults 35 to 64 are concentrated in the nation’s interior, including Appalachia, the Mississippi Delta, and parts of the Midwest. In recent decades, death rates have risen in the interior while declining in coastal regions.

Why Do the Southern States Have Higher Mortality Rates?

The southern states of the United States, often collectively referred to as the “American South,” have historically shown higher mortality rates than their northern counterparts. This trend has prompted extensive research and debate among scientists, public health officials, and policymakers. Let’s delve into some of the main factors contributing to the elevated mortality rates in the South:

1. Socioeconomic Disparities: The South has a higher proportion of its population living below the poverty line than other regions. Economic hardships often correlate with limited access to healthcare, lower educational attainment, and poorer living conditions—all of which can contribute to higher mortality rates.
2. Health Behaviors: Southern states tend to have higher rates of smoking, obesity, and physical inactivity. These factors are strongly linked to various chronic diseases, including heart disease, diabetes, and certain cancers.
3. Dietary Habits: The traditional “Southern diet” is rich in fried foods, processed meats, and sugary beverages. While delicious, such foods can contribute to obesity, high blood pressure, and other health conditions when consumed excessively.
4. Access to Healthcare: Despite the strides made by the Affordable Care Act, many southern states chose not to expand Medicaid. This has left many low-income individuals without affordable healthcare, leading to preventive care and treatment delays.
5. Climate and Environment: The South experiences higher temperatures, which can exacerbate cardiovascular and respiratory conditions. Moreover, some areas, particularly rural ones, have to deal with environmental challenges such as poor air quality and limited access to clean water.
6. Historical Factors: Legacy issues, such as the effects of systemic racism and socioeconomic inequalities that have persisted for generations, can’t be ignored. For instance, Black Americans comprise a significant portion of the South’s population and continue to face challenges contributing to health disparities.
7. Infrastructure and Rural Challenges: The South has a large rural population. Rural areas often have limited medical facilities, fewer healthcare professionals, and longer distances to hospitals. This can lead to delayed or absent medical care, furthering health complications.
8. Cultural and Belief Systems: Cultural attitudes towards medical care, reliance on home remedies, or suspicions about conventional medicine can also affect health outcomes. In specific communities, there might be a preference for traditional healing or a mistrust of the medical system, potentially stemming from historical injustices or personal experiences.

The higher mortality rates observed in the southern states result from a complex interplay of socioeconomic, behavioral, environmental, and historical factors. Addressing these disparities requires a multi-faceted approach, improving access to education and healthcare, investing in infrastructure, and addressing long-standing socioeconomic inequalities.