Poverty, ethnicity cited in rising mortality rate

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Thanks to better preventive measures and healthful lifestyle choices, the average life expectancy in the U.S. has increased steadily in the past few decades.

Unless you are a woman in Washington County, or 179 other counties across the U.S.

According to the study “Reversal of Fortunes: Trends in County Mortality and Cross-County Mortality Disparities in the United States,” the life expectancy of women in the Down East county showed a statistically significant decline between 1983 and 1999. Life expectancy for men in Washington County continued to slowly increase over the same period.

The study, published earlier this spring in PLoS Medicine, an open-access journal of the Public Library of Science, analyzes data taken from 1983 to 1999 and shows Washington County is the only one in New England to show an increased mortality rate for women.

According to the study, 19 percent of American women – nearly 1 in 5 – are now experiencing stagnating or falling life expectancy.

The report does not give specific numbers for each county, such as the age men and women can expect to live, but it says the disturbing trend appears to be driven by increases in death from diabetes, lung cancer, emphysema and kidney failure. According to the report, the trend reflects the long-term consequences of smoking, a habit that women took up in large numbers decades after men did, and the slowing of the historic decline in heart disease deaths in both sexes. It also may represent the leading edge of the obesity epidemic.

Regardless of the causes, any factors contributing to an increase in mortality have one Washington County legislator pushing hard for action and accountability.

“This is unacceptable,” Rep. Anne Perry, D-Calais, said. “Maine cannot ignore this.”

A nurse practitioner, Perry knows firsthand what her constituents face in trying to access quality health care.

“I see these people every day,” she said recently.

The biggest stumbling block, Perry said, boils down to simple economics and the state’s inability or unwillingness to address the economic needs of its rural areas.

“I firmly believe this is a socioeconomic issue,” Perry said. “In Maine, when we look at economic development, the state has not gotten it right.”

High cancer rates

The numbers seem to back up Perry’s belief.

From 1961 to 1983, life expectancy went up everywhere in the U.S. for both sexes. But the study indicates that in the 1980s and through the ’90s, “those who were already disadvantaged did not benefit from the gains in life expectancy experienced by the advantaged, and some became even worse off.”

Those “worse off” counties stopped seeing decreases in their death rates, especially among women, whose rates actually increased, according to the study.

The researchers termed this shift “the reversal of fortunes.”

Perry knows this trend all too well and has only to cite the cancer rate statistics for her home district.

“The annual cancer rate in Washington County is 638 cases a year,” she said of the rate for both sexes. That’s well above Maine’s average of 525 cases per county, “which is already pretty high.”According to census data, Washington County’s population is 33,288.

The next highest rate in Maine is in Penobscot County, with 560 cases reported annually with a population of 147,180.

Washington County also leads the state in total deaths from cancer.

“Maine overall has a high [cancer] mortality rate compared to the rest of the nation,” said Kip Deserres of the Maine Cancer Society. “Washington County is even higher.”

According to the Maine Cancer Registry’s incidence and mortality report for 1997-98, the cancer mortality rate in Washington County was 204.8 per 100,000, a statistic the report says is “significantly higher” than the Maine average of 168.6.

Alongside these figures, data collected by the Margaret Chase Smith Policy Center at the University of Maine indicate Washington County’s 16.1 percent unemployment rate is the highest in Maine and 6 percent higher than the state average.

At the same time, the median household income of $25,869 in that county is 28 percent below the state level and 25 percent below the poverty level for a four-person household.

To compound matters, one out of every eight residents of Washington County lacks health insurance.

Lifestyles

None of this comes as any surprise to Liz Neptune. The 41-year-old mother of six is a member of the Passamaquoddy Tribe and a lifelong resident of Indian Township, near Calais.

She’s also the former director of the local health center and currently acts as a consultant to Indian Health Service, the agency responsible for providing federal health care to American Indians.

According to Neptune, the average age of death for both sexes in Indian Township is low for “a wide variety of reasons,” noting Washington County’s cancer and chronic illness rates.

When it comes to tribal members, Neptune also looks at lifestyle changes her people have experienced over the past century.

“Originally native people were much more active,” Neptune said. “When we were forced onto the reservations it forced us to go from living as hunters and gatherers to relying more on processed foods.”

Generations of natives have grown up on what Neptune referred to as the processed, high-fat “commodity foods” supplied by the government.

Economics and the lack of economic development is another culprit, Neptune said.

“When a mother can buy six boxes of instant macaroni and cheese for less money than fresh vegetables, she will,” Neptune said. “She will buy what’s cheaper to make her dollars stretch further.”

The solution, Neptune said, is increased economic development and solid health information.

Poverty and minorities

All factors, according to the mortality study, contribute to reduced life expectancy.

“Though the study points out some startling and tragic statistics, they are unfortunately not surprising,” Dr. Dora Anne Mills, Maine’s public health director and director of the Maine Center for Disease Control and Prevention, said in an interview last month. “In a real way health is determined by numbers and colors – the numbers on your paycheck and the color of your skin.”

For individuals within ethnic or cultural minority populations living in or near poverty, access to quality health care can be difficult or even impossible, Mills said.

“It is not surprising the counties losing life expectancy are those plagued with poverty and [those] with minority [populations],” she said. “If you were to ask me before this study came out to name a county in Maine that was showing increased mortality, I would have said Washington County.”

In fact, the county is the most culturally diverse in the state, with two American Indian reservations and a large population of Hispanic migrant workers within its boundaries.

Neptune said general health care services are available at the Indian Township Health Center, but those services stop short at specialized care.

“When a person needs to see a specialist like a cardiologist, that becomes a problem,” she said.

At the same time, she noted, Indian Health Services funding pays for 60 percent of the clinic, leaving 40 percent unfunded.

Deserres, like Perry, sees the root of the problem being as much economic as it is medical.

“These kinds of rates often go along with income level,” he said. “Access to health care is another big issue because when people can’t access health care and don’t have insurance it raises the chance of cancer-related mortality.”

The lack of access or ways to afford health care means that poorer Mainers put off screenings and tests that could detect certain diseases and cancers when they are still treatable.

“Access to screenings like mammograms and colonoscopies are the most effective ways to battle two common forms of cancer – breast and colon,” Deserres said. “But they are way underutilized, especially in the most rural areas.”

Preventable conditions

What troubles Perry is the fact that what is leading to those increased mortality rates in Washington County are largely preventable or controllable conditions.

Since about half of all deaths in the U.S. are attributable to a small number of “modifiable” behaviors and exposures such as smoking, poor diet and lack of exercise, Perry agrees with the study’s observation that it “would be a reasonably obvious strategy” to target Washington County for aggressive public health campaigns.

According to the study, those strategies have shown results.

Increased life expectancies from the 1960s to early 1980s were due largely to the fact that the death rate from heart attacks, which had been rising for half a century, began to fall in the late 1960s as people lowered their chances of having a heart attack by modifying risk factors such as smoking, hypertension and high cholesterol. Improvements in medicine – coronary care units, use of aspirin and beta-blocker drugs, and various surgical procedures – greatly increased survival in patients with heart disease. About two-thirds of the longevity gained over the past four decades has come from the decrease in cardiovascular deaths.

These changes were so dramatic that even the poorest and least healthy groups benefited.

By the early 1980s, further life expectancy improvements were becoming confined to areas in the country where people were already healthy.

This was also the period in which women’s life expectancy started to fall in nearly 1,000 counties, including Washington County.

“If you look at the map, women are losing ground nationwide,” Perry said. “They are poorer than men and often live in poverty with children.”

Perry sees a disparity in health care access.

“There is a great deal of health disparity between the haves and the have-nots,” Perry said. “If you have to spend all the money you have to pay bills, pay rent and to eat, health care is not at the top of the list.”

Possible solutions

Any solutions, according to Mills, must come from a multifaceted approach.

“We cannot address this as purely a health issue,” she said. “It is many issues combined, like education, the economy, the environment and infrastructure.”

As an example, Mills points to the high levels of chronic disease in Washington County, where 64 percent of the population is classified as overweight or obese and the rate of nongestational diabetes is 12 percent, almost double the statewide rate of 7 percent.

“It’s like peeling an onion when you start looking for the answers and the solution,” she said. “You have to peel back all the layers to get to the root of why these are problems.”

In Maine, Mills said, lung cancer is the No. 1 cancer killer. Eighty-five percent of the blame of those cases can be laid at the door of smoking, with the other 15 percent due to the prevalence of the naturally occurring radon gas occurring in granite-rich Washington County.

Radon, which is the byproduct of a breakdown of uranium in soil and rock, is the second-leading cause of lung cancer in the U.S. Only smoking causes more lung cancer deaths, and the two together create an especially high risk.

Education and reliable information offered at early ages are the best weapons in the fight against lung disease, Mills said.

“You can say high smoking equals high cancer risk,” she said, “but it’s crucial to offer the economic and educational opportunities.”

The situation is not without hope, Mills said. She cites the recent One County economic development movement in Washington County, which she said does what a successful project must do – bring people together toward a common goal.

“Can things turn around in Washington County? Absolutely,” Mills said. “They already have the best-known ingredient for success – working together.”

Mills also has directed her staff to establish specific health data on Washington County. Such data do exist for the state but currently broken down by region: Aroostook, Penquis, central Maine, Down East, western Maine, midcoast and Cumberland.

“This will give us a handle on what we are looking at,” she said.

For her part, Perry called a meeting last month with state officials from health and economic agencies to begin a discussion on how to reverse the Washington County mortality trend.

She’s optimistic, but knows change will not come about overnight.

“It took awhile to get here, it’s going to take awhile to get out,” Perry said. “I’m calling this my crusade.”

Working for health

Neptune said her own family’s health is, overall, good, though she said all of her children have some degree of asthma, despite the fact that neither she nor her husband smokes.

“My own health is good, but I work at it,” Neptune said.

She does worry about diabetes as both her parents have the disease, something that increases her own risk factor by more than 50 percent.

“It makes me really sad to see these mortality rates, and the fact they are increasing in Washington County,” Neptune said. “We need to get the word out.”

For Neptune, that means educating people on the need and importance of health exams and screenings.

“These are really important for women,” she said. “So often they are so busy taking care of everyone else they don’t care for themselves, and that does not do anyone any good.”

jbayly@bangordailynews.net

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