Gone Before Their Time

In Pittsburgh’s early 20th century industrial economy, danger lurked in rail yards, on the exposed I-beams of tall buildings under construction and in steel mills where gases and fire coexisted. “Ten minutes before, we stood there laughing, and not one of us had an idea there was anything wrong with that furnace,” lawyer and journalist Crystal Eastman quotes a steelworker saying in a 1910 exposé of workplace peril. “That’s the way it is with blast furnace explosions.”

Eastman reported that in a 12-month period spanning 1906 and 1907, workplace accidents in Allegheny County alone claimed 526 workers, most of them under the age of 40—strong evidence that the region was a place where the risk of dying young was high.

More than a century later, it still is. Allegheny County has one of the highest rates of premature deaths in metropolitan America. And it has little, if anything, to do with workplace dangers.

The three rivers are no longer crowded with steel mills. The city’s research universities fuel a burgeoning technology industry. Two major health care systems are expanding across the region. Yet, Allegheny County has the fourth highest age-adjusted premature mortality rate among the 43 U.S. counties with populations greater than 1 million people, according to the latest data from the U.S. Centers for Disease Control and Prevention National Vital Statistics System.

Allegheny County’s age-adjusted mortality rate, which is the rate of death per 100,000 adjusted to reflect the age characteristics of the county, was 390.6 per 100,000 people. New York County, N.Y., which is Manhattan, had the lowest age-adjusted premature death rate of 210.9 deaths per 100,000 people. Wayne County, Mich., home of Detroit, had the highest rate at 489.5 deaths per 100,000 people.

It’s a public health crisis that demands attention, argues Dr. Donald Burke, dean emeritus at the Graduate School of Public Health at the University of Pittsburgh. “We pride ourselves on our great ‘eds and meds.’ You’d think our age-adjusted mortality ranking would improve, but it hasn’t. For some reason, economic progress hasn’t translated into survival.”

Troubling trend

Life expectancy among young and middle-aged adults is in decline across all racial groups in America, according to a study published in the Journal of the American Medical Association (JAMA) last fall.

For decades, life expectancy in the United States had increased. Similar trends were seen across the world. And with ongoing medical advances, many experts assumed the trend would continue.

But life expectancy began to decline in 2014, the long-term analysis of mortality data suggest—a curious anomaly among high-income nations, particularly the United States, which spends more per capita on health care than any country in the world.

Beginning in 1999, three main causes of death drove cause-specific mortality rates for adults aged 25 to 64: Drug overdoses, suicide and alcohol-related diseases.

But the surge in these so-called “deaths of despair” don’t fully explain the increase in mortality. The long rise in life expectancy had begun to slow in the 1980s, decades before the opioid epidemic spread across the country.

The decline is seen across geography, gender and racial and ethnic groups. But there are disparities. Women, for example, have longer life expectancy than men overall. But since 1999, they’ve had a greater increase in midlife deaths related to conditions such as drug overdoses, liver disease and suicide. Non-Hispanic American Indian and Alaska Native populations experience the highest midlife mortality rates of all racial and ethnic groups. The wealthiest 1 percent of the U.S. population lives longer than the poorest 1 percent. Wealthy men live about 14 years longer and wealthy women live 10 years longer compared to their poorest counterparts.

While receding life expectancy is a nationwide trend, it is more concentrated in certain regions, such as New England and the Ohio River Valley. Pennsylvania had one of the highest increases in midlife mortality from 2014 to 2017.

And it’s an abrupt reversal of fortune. From 2012 to 2014, Allegheny County had experienced historically low age-adjusted premature mortality rates. In 2014, Allegheny County had an age-adjusted premature death rate of 346.6 per 100,000 people. But in 2017, the rate jumped to 390.6 per 100,000 people, exceeding the national rate, according to CDC data.

Driving the overall age-adjusted rate of deaths in the county is an increase in deaths among younger populations, particularly adults between the ages of 20 and 44.

Drug overdoses, specifically related to opioids, are a key factor, according to Lynda Jones, epidemiology research associate supervisor at the Allegheny County Health Department. “When we’re looking at all mortality and we see those increases by age, we know that to some extent, that’s a similar population that’s affected by overdoses as well.”

‘Deaths of despair’

Allegheny County has been one of the places in America hardest hit by the opioid epidemic.

During 2017, considered the county’s peak year, 737 opioid overdose deaths were reported, according to Allegheny County Health Department data. The rate of opioid overdose deaths among white and black males is similar.

“Opioids have had such a profound impact on mortality in our population that when we look at 2014 to 2017, it was so impactful that it drove all of our mortality rates,” Jones said.

Suicides in Allegheny County rose almost 50 percent in the past decade, according to a report published by the county Department of Human Services. The county rate of 15.7 suicides per 100,000 people was 17 percent higher than the national rate in 2016, the most recent year that comparable data is available. A host of other suspects also could be contributing to Allegheny County’s high age-adjusted mortality rate. The rate of residents who regularly smoke, for example, is higher than in most other regions. And the county routinely reports greater concentrations of some air pollutants, particularly fine particulates, which studies link to illnesses such respiratory ailments, stroke and heart disease, and premature death.

And some health risks are greater among certain segments of the population. For example, heart disease, the leading cause of death in the county, disproportionately claims the lives of African American men and women. And the rate of infant deaths remains much higher among the county African American population compared to other races, despite marked improvement in recent years, according to data from the Pennsylvania Death Certificate dataset from Pennsylvania Department of Health.

Shifting the tide

The solutions for reversing the course of rising premature deaths in Allegheny County and the nation are as elusive as pinning down all of the causes.

A JAMA editorial published late last year described the revelation of declining life expectancy as a “call to action.” It recognizes that the solution is beyond the reach of medicine alone. It notes that the Institute of Medicine and National Academy of Medicine recommend setting a national life expectancy goal; that others propose financing ways to better integrate social programs into traditional health care; and that more research is needed to understand how social and economic factors, such as income inequality and unstable unemployment influence health. And it calls for broad collaboration across medicine, government and society to improve the well-being of Americans. “Otherwise, the nation risks life expectancy continuing downward in future years to become a troubling norm.”

The Allegheny County Health Department is working on increasing access to the life-saving medication naloxone, while also working on increasing accurate and timely data related to local overdoes to monitor trends and direct overdose prevention projects. The county also provides mental health support services for people in crisis, including a 24-hour hotline, mobile support team and a walk-in center.

There is cause for some optimism. County health officials believe opioid deaths peaked in 2017, reporting 432 deaths in 2018, down from 737 the year before.

But without a broad strategy, it’s difficult to tackle a problem as complex as premature mortality whose causes are poorly understood and could range from drug overdoses to distracted drivers, childhood obesity and unhealthy air quality. “We have a terrific health system,” Burke said. “If we train the full attention of the health system, universities, government and corporations on this problem, surely we can solve it.”