In 2015, a phenomenon coined as ‘Deaths of Despair’ (DoD) emerged in the US, highlighting an alarming increase in mortality due to drugs, alcohol, and suicides, particularly among white men without a college education. Here, Christine Camacho and Dr Luke Munford explore the spatial patterning of these deaths in England, where an estimated 46,200 lives were lost to Deaths of Despair between 2019 and 2021. They identified stark geographical inequalities. The study emphasized that Deaths of Despair are not inevitable – but a consequence of inequitable resource distribution.

• On average, areas in the North have considerably higher rates of DoD; areas with high unemployment rates, high proportions of White British ethnicity, and urban areas were associated with an elevated DoD risk.
• Blackpool had the highest rate of DoD of any local authority, while the North East had the highest regional rate – the lowest rate of DoD was in London.
• Preventative policies may require geographical tailoring – devolution policies may offer the potential to deliver locally tailored solutions.
• However, national policies to redress imbalances in access to economic opportunities, the labour market, and housing are also needed.

Deaths of Despair (DoD) are deaths from drugs, alcohol, and suicide. Researchers have defined these deaths in different ways; we included alcohol-specific and drug-related deaths, and deaths from suicide – including deaths of undetermined intent – as DoD. While these deaths have different causes, they are also closely intertwined. Alcohol and drug misuse are important risk factors for suicide, and overdoses often involve both drugs and alcohol, underscoring the complex and interconnected nature of these issues. DoD are an important public health issue because there is evidence that they are increasing, and they impact some groups of the population more than others.

Previous research in the US has suggested that the underlying cause of these deaths is long-term economic disadvantage and a breakdown of community and social structures. Subsequent studies have shown that DoD rates are associated with a range of socioeconomic factors such as labour market policies, income inequality, housing evictions, and workplace automation.

The UK landscape: inequalities and ‘left behind’ communities

The UK is a wealthy but unequal country, ranking fourth highest in regional economic inequalities among OECD countries. The North of England bears the brunt of these inequalities, experiencing lower life expectancy and economic productivity gaps, while nationally, coastal communities grapple with a higher burden of ill health and substance misuse. Persistent inequalities, evolving over recent decades, have led to the creation of what is termed ‘left behind’ communities.

Previous studies from researchers at The University of Manchester have highlighted the links between economic and health disparities, with lower wages and poorer job availability in more deprived communities contributing to a higher health burden, which in turn limits healthy life expectancy. As a result, people in ‘left behind’ neighbourhoods are more likely to experience chronic health issues which keep them out of the labour market. In a vicious cycle, these health inequalities create socio-economic disparities, which feed back into health inequalities.

To address this, the Government launched their flagship ‘levelling up’ agenda which aims to address spatial disparities – though there are questions about whether funding allocation is proportionate to the needs of regional economies.

Unique in its approach, this study aims not only to uncover the spatial patterns of DoD in England, but also to identify the socioeconomic and demographic factors linked to elevated risk. The starting point for this analysis was calculating the rates of DoD at local authority level. We then explored associations between the local authority DoD rates and a range of variables, including deprivation, employment type, population density, income, income inequality, ethnicity, social fragmentation, and economic inactivity.

Between 2019 and 2021, 46,200 lives were claimed by DoD in England, illuminating the profound impact of this crisis. The average DoD rate was 34 per 100,000 people. The leading cause of DoD varied by age group, with suicide dominating in individuals under 30; drugs in the 30-44 age bracket; and alcohol claiming prominence in those aged 45 and over. Overall, alcohol-specific deaths emerged as the largest contributor, constituting 44% of all such fatalities.

DoD rates exhibited significant regional disparities, with the North East bearing the highest burden, averaging 55 DoD per 100,000 people. In stark contrast, London had the lowest DoD rate, with around 25 per 100,000, underscoring the geographical diversity in the prevalence of DoD. Coastal areas also had higher rates of DoD before adjustment for other factors. At the local authority level, Blackpool, in the North West, had the highest rate of DoD (84 per 100,000), compared to Barnet, in North London, with the lowest rate of 15 per 100,000.

We identified the area-level factors associated with DoD. These include unemployment rates, higher proportions of White British ethnicity, solitary living, higher rates of economic inactivity, employment in elementary occupations, and urbanicity as significant contributors to the elevated risk of DoD. Beyond the numbers, this research emphasises that DoD are not inevitable – but rather a tragic consequence of inequitable resource distribution. Our findings show clearly that the impact of DoD risk factors is not uniform across England.

Righting a wrong – policy solutions to regional inequality

The implication is clear: preventive policies must be geographically tailored, with no one-size-fits-all solution to levelling up. The English policy of devolving decision-making and funding to local and regional governments offers one avenue for delivering locally tailored solutions.  Greater powers are needed for Metro Mayors to direct financial, health, and community resources towards the areas hit hardest by DoD. This process has begun in Greater Manchester and the West Midlands, with their ‘trailblazer deal’, but this new data highlights the urgent need to accelerate the devolution of place-based powers.

However, the national policy context – prioritising equitable access to economic opportunities, the labour market, and housing – remains paramount in shaping the trajectory of DoD. Tackling the socioeconomic factors that underpin DoD requires inter-departmental collaboration, cross-party working, and a long-term commitment to levelling up. The responsibility falls across government to ensure health is embedded in all decisions aimed at reducing inequalities.

Other national governments have recognised the importance of tackling regional disparities. It is an oft-cited figure that, since reunification, Germany has spent almost €2 trillion on regional equality. In the UK, the ‘levelling up’ agenda seeks to address regional imbalance, but concerns have been raised as to whether this funding is being allocated equitably. Evidence-based approaches, such as the use of composite indicators to support decision-making and funding allocation, are one potential solution to this. Considering the socioeconomic factors that underpin them, measuring rates of Deaths of Despair over time could be one way to assess whether progress is being made in levelling up.

In laying bare the areas in England bearing the greatest human cost of systemic failings, this research underscores the imperative for decisive action to address the root causes and reshape the landscape of Deaths of Despair.