What's Killing Poor White Women?

AP Images/Lars Halbauer

On the night of May 23, 2012, which turned out to be the last of her life, Crystal Wilson baby-sat her infant granddaughter, Kelly. It was how she would have preferred to spend every night. Crystal had joined Facebook the previous year, and the picture of her daughter cradling the newborn in the hospital bed substituted for a picture of herself. Crystal’s entire wall was a catalog of visits from her nieces, nephews, cousins’ kids, and, more recently, the days she baby-sat Kelly. She was a mother hen, people said of Crystal. She’d wanted a house full of children, but she’d only had one.

The picture the family chose for her obituary shows Crystal and her husband holding the infant. Crystal leans in from the side, with dark, curly hair, an unsmiling round face, and black eyebrows knit together. She was 38 and bore an unhealthy heft, more than 200 pounds. Crystal had been to the doctor, who told her she was overweight and diabetic. She was waiting to get medicine, but few in her family knew it, and no one thought she was near death.

Crystal’s 17-year-old daughter, Megan, split her time between her parents’ house in Cave City, Arkansas, and that of her boyfriend, Corey, in nearby Evening Shade. Megan made sure that each set of grandparents could spend time with the baby. The night before Crystal’s death, Megan and Corey were moving with his parents to a five-acre patch near Crystal. Megan and Corey were running late, so they didn’t pick the baby up until 11 P.M. Crystal seemed fine. “You couldn’t tell she was sick,” Megan says. “She never felt sick.” They went back home, and Megan got a text from her mom around midnight. “She said she loved me, give Kelly kisses, and give Corey hugs and tell him to take care of her girls and she’d see me in the morning. I was supposed to drop Kelly off at ten o’clock and finish moving.”

Instead, at around 9:30 the next morning, when Megan was getting ready to leave, Corey’s grandfather called and said Crystal was dead. Megan didn’t believe him. If one of her parents passed, it had to be her dad. “I thought it was my dad that died because he was always the unhealthy one.” Megan left Kelly with her mother-in-law and raced with Corey and his dad in the truck, hazards on, laying on the horn, and pulled into the dirt driveway outside her parents’ tan-and-brown single-wide trailer. “Daddy was sitting there in the recliner crying,” Megan says. “It was Momma gone, not him.” Crystal had died in her bed early in the morning.

Just after 10 A.M., nearly every relative Crystal had was in the rutted driveway in front of the trailer. Crystal was the last of six children and considered the baby of the family. She was the third sibling to die. Her brother Terry, the “Big Man,” who hosted all the holiday dinners and coached the family softball team, had died three months earlier at age 47, and her sister Laura, whom everybody called Pete, died at age 45 in 2004. The police—dozens, it seemed, from the county and from the town—had arrived and blocked off the bedroom where she lay and were interviewing people to figure out what had killed her.

The coroner arrived and pronounced Crystal dead at 11:40. Her body was rolled out on a gurney and shipped to the state lab in Little Rock. One of the officers, Gerald Traw, later told me an autopsy is routine when someone dies without a doctor present. “We like to know why somebody died,” he says.

Courtesy Wilson Family

Everything about Crystal’s life was ordinary, except for her death. She is one of a demographic—white women who don’t graduate from high school—whose life expectancy has declined dramatically over the past 18 years. These women can now expect to die five years earlier than the generation before them. It is an unheard-of drop for a wealthy country in the age of modern medicine. Throughout history, technological and scientific innovation have put death off longer and longer, but the benefits of those advances have not been shared equally, especially across the race and class divides that characterize 21st--century America. Lack of access to education, medical care, good wages, and healthy food isn’t just leaving the worst-off Americans behind. It’s killing them.

The journal Health Affairs reported the five-year drop last August. The article’s lead author, Jay Olshansky, who studies human longevity at the University of Illinois at Chicago, with a team of researchers looked at death rates for different groups from 1990 to 2008. White men without high-school diplomas had lost three years of life expectancy, but it was the decline for women like Crystal that made the study news. Previous studies had shown that the least-educated whites began dying younger in the 2000s, but only by about a year. Olshansky and his colleagues did something the other studies hadn’t: They isolated high-school dropouts and measured their outcomes instead of lumping them in with high-school graduates who did not go to college.

The last time researchers found a change of this magnitude, Russian men had lost seven years after the fall of the Soviet Union, when they began drinking more and taking on other risky behaviors. Although women generally outlive men in the U.S., such a large decline in the average age of death, from almost 79 to a little more than 73, suggests that an increasing number of women are dying in their twenties, thirties, and forties. “We actually don’t know the exact reasons why it’s happened,” Olshansky says. “I wish we did.”

Most Americans, including high-school dropouts of other races, are gaining life expectancy, just at different speeds. Absent a war, genocide, pandemic, or massive governmental collapse, drops in life expectancy are rare. “If you look at the history of longevity in the United States, there have been no dramatic negative or positive shocks,” Olshansky says. “With the exception of the 1918 influenza pandemic, everything has been relatively steady, slow changes. This is a five-year drop in an 18-year time period. That’s dramatic.”

Researchers had known education was linked to longer life since the 1960s, but it was difficult to tell whether it was a proxy for other important factors—like coming from a wealthy family or earning a high income as an adult. In 1999, a Columbia economics graduate student named Adriana Lleras-Muney decided to figure out if education was the principal cause. She found that each additional year of schooling added about a year of life. Subsequent studies suggested the link was less direct. Education is strongly associated with a longer life, but that doesn’t mean that every year of education is an elixir. “It is the biggest association, but it is also the thing that we measure about people the best,” Lleras--Muney says. “It is one of those things that we can collect data on. There could be other things that matter a lot more, but they’re just very difficult to measure.”

As is often the case when researchers encounter something fuzzy, they start suggesting causes that sound decidedly unscientific. Their best guess is that staying in school teaches people to delay gratification. The more educated among us are better at forgoing pleasurable and possibly risky behavior because we’ve learned to look ahead to the future. That connection isn’t new, however, and it wouldn’t explain why the least-educated whites like Crystal are dying so much younger today than the same group was two decades ago.

Cave City gives itself the low-stakes title of “Home of the World’s Sweetest Watermelons.” Beneath the ground, the Crystal River carves out the caverns that lend the town its name. Above it, 1,900 people live in single-wides in neighborhoods dotted with fenced lawns or along spindly red-dirt trails off the main highway. In this part of Arkansas, the Ozark Plateau flattens to meet the Mississippi embayment, and the hills give way to rice paddies. About 17,000 people live in Sharp County, a long string of small towns with Cave City at the bottom and the Missouri border at the top. Most of the residents are white—96 percent—with a median household income of $29,590. Nearly a quarter live in poverty, and Crystal was among them; for most of her married life, she relied on income from her husband’s disability checks.

For work, people drive to the college town of Batesville, about 20 minutes south, which has a chicken-processing plant that periodically threatens to close and an industrial bakery with 12-hour shifts that make it hard for a mother to raise children. Less than 13 percent of county residents have a bachelor’s degree. Society is divided into opposites: Godly folk go to church and sinners chase the devil, students go to college and dropouts seek hard labor, and men call the shots and women cook for them.

Davidiad/Wikimedia

Crystal’s parents, Junior and Martha Justice, had moved to the area when her three oldest siblings were still toddlers. “My aunt told my dad that he could make better money up here, but it wasn’t so,” says Linda Holley, one of Crystal’s sisters. Junior farmed, which fed his family and brought in a little money. He found a piece of land on a country road called Antioch and bought a prefabricated home from the Jim Walters company. It was on this land they had their next three children. Crystal, born July 6, 1973, was the sixth and youngest.

Their life was old-school country. They raised chickens and goats and grew their own vegetables. The house was small, with only three bedrooms. Crystal’s closest sibling, Terry, was 7 years older. Linda was a full 15 years older than Crystal, which made her more like a second mom than a sister. When Crystal was two, Linda’s twin sister, Pete, began having children and, fleeing a string of abusive relationships, turned over custody to her parents. Having four slightly younger nieces and nephews in the house gave Crystal playmates her own age.

It was Linda, the doting older sister and aunt, who would take all the kids to Dogpatch, a creaky little Ozarks amusement park based on the comic strip, with actors playing Daisy Mae and Li’l Abner. Linda keeps Polaroids of Crystal from that time. They show her with long, curly blond hair and often half-clothed, happy, covered in clay and mud. “Grandpa used to call her his little Shirley Temple,” says Crystal’s niece, Lori.

When Crystal was starting out in elementary school, the family moved to a trailer to be closer to town. Her dad worked occasionally for lumber companies, and the proximity made jobs easier to find. Crystal was well behaved in school, and teachers would ask Lori, only two years behind, “Why aren’t you like her, she was so quiet and shy?” Crystal loved basketball and, especially, softball, which she played in summer clubs even as an adult. As she got older, her hair darkened and she became stocky and muscular. She played ball like a bulldozer and was aggressive on the field and mouthy off. The whole family would play and bicker and joke. Crystal would smack people across the butt with the bat if they weren’t moving fast enough.

 “It wasn’t until we got in high school that I realized she was struggling so bad in school,” Lori says. “I was in the seventh grade, and she was in the ninth, and I wasn’t really smart myself. But I could help her do some of her work.” In 1988, Junior died from lung cancer at age 55. Both he and Martha were smokers. The next year Crystal met Carl Wilson, whom everybody called Possum. He was related to a cousin through marriage and, at 28, was 12 years her senior. They kept their relationship secret for a few months. “He came up to see her at the school,” Lori says. “So I pretty much put two and two together. I was the one that told my grandmother.” Lori thought that would put an end to it; instead, Martha let them marry. According to Linda, Martha had one admonition for Possum: “Momma said, ‘As long as you take care of her and don’t hit her, you have my permission.’ He done what he could do for her. They was mates.”

Possum moved in with the family in the trailer. He and Crystal had one room, Martha another, and the four nephews and nieces shared two bunk beds in the third. Crystal dropped out in the tenth grade because she had married. That was the way things were. None of Crystal’s siblings finished high school. Instead, they became adults when they were teenagers. Crystal would spend the rest of her years as a housewife to a husband who soon became ill and as a mother to a daughter who would grow up as fast as she did. 

 

Researchers have long known that high-school dropouts like Crystal are unlikely to live as long as people who have gone to college. But why would they be slipping behind the generation before them? James Jackson, a public-health researcher at the University of Michigan, believes it’s because life became more difficult for the least-educated in the 1990s and 2000s. Broad-scale shifts in society increasingly isolate those who don’t finish high school from good jobs, marriageable partners, and healthier communities. “Hope is lowered. If you drop out of school, say, in the last 20 years or so, you just had less hope for ever making it and being anything,” Jackson says. “The opportunities available to you are very different than what they were 20 or 30 years ago. What kind of job are you going to get if you drop out at 16? No job.”

In May, Jennifer Karas Montez of the Harvard University Center for Population and Development Studies co-authored the first paper investigating why white women without high-school diplomas might be dying. Most research has looked at which diseases are the cause of death, but Montez and her co-author wanted to tease out quality of life: economic indicators like employment and income, whether women were married and how educated their spouses were, and health behaviors like smoking and alcohol abuse. It is well known that smoking shortens life; in fact, smoking led to the early deaths of both of Crystal’s parents and her sister and brother. Crystal, though, never smoke or drank. But the researchers discovered something else that was driving women like her to early graves: Whether the women had a job mattered, and it mattered more than income or other signs of financial stability, like homeownership. In fact, smoking and employment were the only two factors of any significance.

At first, Montez and her co-author suspected that women who are already unhealthy are less able to work and so are already more likely to die. When they investigated that hypothesis, however, it didn’t hold up. Jobs themselves contributed something to health. But what? It could be, the authors suggested, that work connects women to friends and other social networks they otherwise wouldn’t have. Even more squishy sounding, Montez wrote that jobs might give women a “sense of purpose.”

Better-educated women are the most likely to work and to achieve parity with men: Seventy--two percent are in the workforce, compared with 81 percent of their male counter-parts. Women without high-school diplomas are the least likely to work. Only about a third are in the workforce, compared to about half of their male counterparts. If they do find work, women are more likely than men to have minimum-wage jobs. They account for most workers in the largest low-paying occupations—child-care providers, housecleaners, food servers. Even if they do have minimum-wage jobs, this group of women is more likely to leave the labor force to take care of young children because child care is prohibitively expensive.

Montez’s joblessness study, however, raised more questions. Would any job do? What does giving women a “sense of purpose” mean? And why would joblessness hit white women harder than other groups? Overall, men lost more jobs during the Great Recession. Why are women losing years at a faster rate?

 

Cave City life revolves around its rivers, thick with runoff from the mountains and barreling toward the Mississippi. Crystal loved the area, but she also didn’t know anything else. She hunted squirrels and rabbits in the fall, but spring was filled with what she loved most. School ends, and softball season begins. It is a brief, lovely time, before humidity and mosquitoes, when the world smells of wildflowers and dirt and storms. Every year, one of Crystal’s brothers made sure she had a fishing license for the spring-swollen White River and the less touristy Black River, where they had better hauls. People come from around the state to float lazily, drunkenly down the rivers in canoes and rafts. Songbirds come too—buntings, mockingbirds, whippoorwills, woodpeckers—settling in for the season near the quieter streams, ponds, and water-filled rice paddies. Deer fill the kudzu-covered woods. Copperhead snakes awakened from hibernation nest in muddy puddles.

Crystal wanted to start a family as soon as she was married but couldn’t. Her first three pregnancies, in the early ’90s, ended in miscarriages. The first two occurred so late she gave the babies names, Justin and Crystal; the last was a set of twins. None of her relatives knew if she ever went to a doctor to find out why she miscarried. “I just thought maybe it was one of those things, you know, some people can have them and carry them and some can’t,” Lori says. Megan said her mother had had “female cancer,” a catchall phrase for cervical cancer and the infections and dysplasia leading up to it.

When Lori’s son was born, Crystal teased her about stealing him. She was always volunteering to baby-sit the kids in the family. When Crystal finally got pregnant with Megan, no one was sure she would make it, least of all Crystal and Possum. “They ended up just praying for me,” Megan says. She was born July 20, 1994, and became the center of Crystal’s world.

By the time Megan was born, Crystal and Possum were living in their own trailer but were struggling financially. Possum had worked the first four years of their marriage at the chicken-processing plant before quitting for good because of health problems. An accident on an oil rig when he was a teenager had left him with a plate in his skull. Chicken-processing plants are tough places to work, and besides, he qualified for disability. Crystal spent her life taking him to specialists—he was covered by Medicaid—but the problems piled up. He had a congenital heart condition and a bad back. A young-old man.

When Megan was 12, Crystal worked for a brief spell as a housekeeper at a nursing home in Cave City, where Linda and Lori worked. Mostly, though, she stayed home to take care of Possum and Megan. Baby-sitting brought in small amounts of cash, but she and Possum relied on disability, which was about $1,000 a month. Outside of a brief trip to Texas after Megan was born to show her off to Possum’s family, and a trip to a small town near St. Louis to visit a niece after one of the trailers they lived in burned down, Crystal passed her entire life in Cave City.

Crystal spent what money she had on Megan. She gave her any new toy she wanted and, later, name-brand clothes, a four-wheeler, a laptop, and a phone. When Megan started playing softball, Crystal spent money on shoes, gloves, and club fees. “Crystal was a super mom,” says Steve Green, the school superintendent and Megan’s softball coach. “They didn’t have a lot of revenue, but they put everything they had into Megan.” Crystal and Possum made it to every practice and every game, even if it meant driving for an hour, deep into the mountains. They brought snacks and sports drinks for Megan’s teammates. Crystal would watch her nieces, nephews, and cousins’ kids play, and she still played for her family team in Batesville. Crystal went with Linda to a missionary Baptist church near the family road in Antioch, but she and Possum weren’t every-Sunday Christians—it was the softball field her spring weekends revolved around. But when Terry was diagnosed with cancer in 2009, the family stopped playing, and Crystal lost her favorite activity.

When her relatives look back, they think Crystal was probably lonely. Her mother had died three years after Megan was born. Although she and Possum had a Ford Contour, Crystal seldom drove, relying on relatives to come by to take her to the grocery store. It was a chance to visit. When Linda’s daughter took her truck-driver husband to pick up his 18-wheeler for his next haul, Crystal would always want to go with them. She would call her family members throughout the day, gossiping. She didn’t stir up trouble, but she reveled in drama. Crystal would often go to Linda’s for homemade biscuits and gravy for breakfast, and she’d ask Linda to buy her liter bottles of Dr Pepper whenever she ran out. She was addicted to Dr Pepper. Sometimes, relatives paid for Possum’s medicine; Linda’s daughter remembers paying as much as $64 in one visit. Crystal’s nieces and nephews had gotten older and started their own families, and now she relied on them as much as she had her older siblings.

 

Another mystery emerged from the lifespan study: Black women without a high-school diploma are now outliving their white counterparts.

As a group, blacks are more likely to die young, because the factors that determine well-being—income, education, access to health care—tend to be worse for blacks. Yet blacks on the whole are closing the life--expectancy gap with whites. In a country where racism still plays a significant role in all that contributes to a healthier, longer life, what could be affecting whites more than blacks?

One theory is that low-income white women smoke and drink and abuse prescription drugs like OxyContin and street drugs like meth more than black women. Despite Crystal’s weight and diabetes, those problems are more common among black women and usually kill more slowly. Meth and alcohol kill quickly. It could be that white women, as a group, are better at killing themselves.

Still, why would white women be more likely to engage in risky behaviors? Another theory is  that the kind of place people live in, who is around them, and what those neighbors are doing play a central role. Health is also a matter of place and time.

In March, two researchers from the University of Wisconsin reported that women in nearly half of 3,140 counties in the United States saw their death rates rise during the same time period that Olshansky studied. The researchers colored the counties with an increase in female mortality a bright red, and the red splashed over Appalachia, down through Kentucky and Tennessee, north of the Cotton Belt, and across the Ozarks—the parts of the South where poor white people live. Location seemed to matter more than other indicators, like drug use, which has been waning. The Wisconsin researchers recommended more studies examining “cultural, political, or religious factors.”

Something less tangible, it seems, is shaping the lives of white women in the South, beyond what science can measure. Surely these forces weigh on black women, too, but perhaps they are more likely to have stronger networks of other women. Perhaps after centuries of slavery and Jim Crow, black women are more likely to feel like they’re on an upward trajectory. Perhaps they have more control relative to the men in their communities. In low-income white communities of the South, it is still women who are responsible for the home and for raising children, but increasingly they are also raising their husbands. A husband is a burden and an occasional heartache rather than a helpmate, but one women are told they cannot do without. More and more, data show that poor women are working the hardest and earning the most in their families but can’t take the credit for being the breadwinners. Women do the emotional work for their families, while men reap the most benefits from marriage. The rural South is a place that often wants to remain unchanged from the 1950s and 1960s, and its women are now dying as if they lived in that era, too.

Crystal’s world was getting smaller and smaller and more sedentary. Everyone was worried about Possum, but Crystal’s own health was bad. She’d had a cystic ovary removed when Megan was 13, and about a year before her death she had a hysterectomy. The surgery was necessary after Crystal had started hemorrhaging, which was brought on by another miscarriage—something her family didn’t know about until the autopsy. It’s unclear when she learned she was a diabetic. Megan thinks her mom might have heard it for the first time when she was pregnant with her, but Crystal never had regular medical care because she didn’t qualify for Medicaid as Possum did.

Megan started spending more time away from her mom in the tenth grade, when Corey and his family moved to town. Crystal consented to their high-school romance, though she warned Corey that if he ever hit her daughter, she’d put him in the ground herself. Within a year of going out with Corey, Megan was pregnant. She swears she didn’t know it until she was seven and a half months along, when Corey’s mother made her take a pregnancy test. They had a short time to prepare for Kelly’s birth in February 2012, but Crystal was happy about the new baby. It was a way for her to have another child. But after Kelly’s birth, Crystal and Megan argued; Megan was worried her mother would spoil Kelly. Because Corey’s father worked, his family had a bit more money, and they bought more baby clothes than Crystal could, which only made her feel worse.

In the final months of her life, Crystal complained of chest aches, but when she went to the emergency room, the doctors assured her it wasn’t a heart attack. She said that she felt like she had the flu or allergies. In hindsight, it was after Terry’s death—he died a week after Kelly was born—when Crystal really began to suffer. He had been the linchpin of the family, and now they were breaking apart. After he died, Crystal would call Linda’s daughter and say, “I wish God would have took me instead of Terry.” Crystal posted regularly about Terry on her Facebook page. Crystal had stopped coming to Linda’s for breakfast, too, because Possum was growing sicker and had started falling when he tried to walk on his own. He was diagnosed with cancer about a week before Crystal’s death. “I couldn’t help but wonder if maybe some of it might have been attributed to her system just being drug down from having to take care of Carl and Megan,” says Steve Green, the school superintendent. “Just everyday stress.”

The night before she died, Crystal made herself a peanut-butter-and-jelly sandwich for dinner. After Megan took Kelly home, she went to bed and fell asleep, but Possum said she woke up at 1 A.M., said she was thirsty, and went to the kitchen. She was a fitful sleeper, and she returned to bed. When Crystal wasn’t up before him the next morning, it struck Possum as odd, but he let her sleep. Crystal usually called her relatives around 6 or 7 A.M. to see what their plans were for the day. They wondered if something was wrong when their phones didn’t beep. Finally, Possum sent in his brother, who’d been staying with them, to wake Crystal up; they were always going after each other, and he thought the teasing would spur her out of bed.

Crystal’s funeral was small, mostly attended by family, and held at the funeral home in Cave City. They buried her in a tiny graveyard next to a little white chapel on Antioch Road, near the land where Crystal was born. Megan went to stay with Corey’s family, and they offered to buy Possum a prefabricated barn so he could come live near them, but there was no need. He spent most of the next four weeks in and out of the hospital, until he died of massive heart failure on June 22. Possum was buried right beside Crystal. Both graves are marked with temporary notices. Linda has promised Megan she will help buy tombstones.

The medical examiner’s investigation into Crystal’s death was closed because it was determined she died of natural causes. The police report lists no official cause. With untreated, unmanaged diabetes, her blood would have been thick and sticky—the damage would have been building for years—and it could have caused cardiac arrest or a stroke. Linda has her own explanation: “Her heart exploded.” And, in a way, it had.

 

After her mom’s death, Megan was 17, hitched, and living on the same land where Crystal had given birth to her. Was it going to be the same life over again?

At school, a number of administrators and teachers stepped in to make sure Megan felt supported; one of them was the technology coordinator for the Cave City schools, Julie Johnson. With big gray eyes and a neat gray bob, she seems younger than 46. When I visited the school this spring, Julie showed me a picture of Megan with Kelly, Corey, and his family that Megan copied and gave to her. They became close last winter when Julie walked into one of Megan’s classrooms and the teacher asked, “Have you congratulated Megan?” Julie turned to her and said, “What have you done, sister?” Megan told her that she’d given birth only a week before but that she’d wanted to come back to school. Julie said, “Dang, you’re tough!”

Julie has seen a lot of teen mothers. Arkansas ranks No. 1 in the country in teenage births. About a month before Megan gave birth to Kelly, another young woman from the school had gotten married and had a baby, then died mysteriously. Nobody knew what had caused it, and the girl, Bethany, was in the back of Julie’s mind when she saw Megan. “I’ve been in education for 25 years. I kind of got a good eye and sensed where she was coming from. And I was troubled because, as I kept thinking, OK, if a teacher here at school has a baby, they have a big shower for her, and if somebody at church has a baby, they have a shower for her, but if you have a child as a child, we don’t do anything.”

She prayed on what to do, and prayed some more. It led her to start the Bethany Project, a donation program that would give Megan and other young mothers baby clothes, school supplies, and community support. Megan was only in the spring of her junior year when she had Kelly. Megan told Julie she’d promised her mother she’d stay in school—Megan told me Crystal wanted her to have a good job so she could take care of Kelly and spoil her rotten—and Julie thinks Megan’s mother-in-law helped her uphold her promise. “Corey’s mother, I think she would have fought the devil to make sure those two finished school.” They did. Megan and Corey finished school on May 3 of this year, were married eight days later on May 11, and then graduated on May 18, just a few days shy of the anniversary of Crystal’s death. Megan found a job at Wendy’s and plans to enroll in the community college in Batesville. Finishing college would give her the best chance to escape her mother’s fate.

Julie knows a lot of young women who will never break the cycle. She has her own thoughts about what might be dragging down their life expectancy. “Desperation,” she says. “You look at the poverty level in this county—I love this place. It’s where I’m from. I don’t want you to think I’m being negative about it.” But she gestures toward the highway and notes how little is there: a few convenience stores, a grocery, and a nursing home. You have to drive north to the county seat in Ash Flat for a Walmart, or you can negotiate traffic in Batesville, where you might get a job at the chicken plant or a fast-food restaurant. “If you are a woman, and you are a poorly educated woman, opportunities for you are next to nothing. You get married and you have kids. You can’t necessarily provide as well as you’d like to for those kids. Oftentimes, the way things are, you’re better off if you’re not working. You get more help. You get better care for your kids if you’re not working. It’s a horrible cycle.

 “You don’t even hear about women’s lib, because that’s come and gone. But you hear about glass ceilings, and I think girls, most especially girls, have to be taught that just because they’re girls doesn’t mean they can’t do something. That they are just as smart, that they are just as valuable as males. And we have to teach boys that girls can be that way, too. They all need the love, nurturing, and support from somebody from their family or who’s not their family. Somebody who’s willing to step up. There has to be something to inspire kids to want more, to want better. And they have to realize that they’re going to have to work hard to get it. I don’t know how you do that.

“It’s just horrible, you know? I don’t know if ‘horrible’ is the right word.” Julie puts her face into her hands. “The desperation of the times. I don’t know anything about anything, but that’s what kills them.”

Comments

Well-written article, thanks. Sounds as if Crystal might have suffered from polycystic ovary syndrome. ...Coincidentally, I just yesterday re-read a 1999 article from The Atlantic Monthly (The New Germ Theory) that points to infection as a possible cause for PCOS. .... my point being that it seems so often we look at superficial culprits - especially life style behaviors - that we can use to lay the cause of death on the deceased, thereby not seeing other possible suspects.

I replied before I saw your post! Yes and YES!! PCOS is SO overlooked in our country! Could you possibly send me a link to that article, or copy of that article? My e-mail is: ChristineEnedy@hotmail.com. Thank YOU!

It sounds like she had PCOS (Polycystic Ovarian Syndrome). It is an endocrine disorder in women that can cause: cysts on your ovaries, hormone problems, miscarriage, fertility issues, weight gain, abnormal hair growth, high blood pressure, diabetes, depression, anxiety and several other issues.

I have PCOS... My grandmother who died when she was 38 probably had it (she looks just like me from photographs that I have seen of her). Grandma died at home after a stroke, almost the exact same situation as this lady - poor and uneducated. I am glad to be an educated woman (now 42) who has been able to manage my condition through medications, and being able to have good medical care.

Some doctors are saying that nearly 10% of women have PCOS. I am wondering if this factor was ever considered into this study? It NEEDS to be! PCOS goes unnoticed so much in this country because it has so many symptoms and there is no cure! People are more interested in helping to prevent breast cancer (because that is something that can be seen... removing a breast... but, when the problem is inside, especially dealing with a woman's reproductive health people don't want to talk about it).

There HAS TO BE a correlation here! Someone NEEDS to look into it!

Correlation is not causation.

Thanks for contributing your spectacular wit and sparkling observations to the discussion.

Hi Christine - here's the link: http://www.theatlantic.com/past/docs/issues/99feb/germs.htm. PCOS is one of a number of diseases that some researchers think might be the result of an infection. I did a minor check yesterday to see if there's been any new work done on the possibility, but I found none.

Excellent article. I understand why the comments are directed toward PCO- a likely cause-of-death of Crystal, the central character in this essay. To me, the message to the article is the devastation of thousands of women by societal forces that should be controlled, rather than caused, by political and economic measures. As a 90 year-old retired physician, I have seen hundreds of patients like Crystal. When I was born, there were about 100 million Americans, and a billion people in the world. Now there are over 300 mlllion of us among the eight billion on earth. The outlook for the Crystals of the world is bleak. At the very least, we need to empower women to choose responsible parenthood. Craig B. Leman, M.D.

"...we need to empower women to choose responsible parenthood..." Yes, I agree, Dr. Leman.

And my next bit is not directed at you, but because you're a doctor and you raise the issue:

Part of this empowerment will require that doctors honor their patients' requests for sterilization rather than refusing to do such surgery because of an arbitrary age minimum for fear the woman might change her mind later. Such an arbitrary refusal of care denies the self-determination of an adult person. It infantilizes women. ....

Only two days ago, I talked with a woman whose doctor will not sterilize her because of her age. It happens this woman knows she doesn't want children. This woman knows that she is unable to support (now or in the future) a child financially and in some other ways because of the nature of an illness she has. This woman has been disempowered.

I have worked in the adoption field and I saw women who already had more children than they could afford (financially/emotionally/practically) and they knew they couldn't afford more children, but their doctors refused to sterilize them because of their age.

In some hospitals, such as in the rural areas described in the article, which serve poor women, hospitals won't sterilize a woman at the time she delivers a baby because the hospital/doctor won't receive as high a Medicaid reimbursement if it's done as part of another procedure. Instead, they bifurcate the procedures, so the woman has to find childcare, transportation, and perhaps time off work to go to the hospital a *second* time in order to get sterilized. Often, these obstacles result in the sterilization not being done.

While obesity is a factor in Crystal's case, I believe that what has been wiping out so many poor white women is that they have become non-existent (at best), as far as this generation is concerned. This generation has shown tremendous apathy toward US poverty. Progressive media, which should know better, has merely called for job creation for the past 30 year or so. You can't buy a loaf of bread with promises of eventual jobs. Beyond an apathetic left, poor white women are (at best) subject to ongoing dehumanization while effectively remaining trapped in poverty. "White trash/trailer trash," etc. They have no representation whatsoever in government, no voice in the public forum. Those masses who are bottom-wage workers know that they're a single job loss from losing everything, with no way back up. How do you get a job job without a home address, phone, bus fare? Not many women survive very well on the streets. These women are on a tight rope with no safety net below.

"...we need to empower women to choose responsible parenthood..." This is actually a tremendously complex issue, where choosing to move forward with a relationship can be a matter of survival, itself. and it is apparent that those who have never been in that position are quite clueless about such circumstances. Regardless, it is time (after all these centuries) to begin grasping the concept that every pregnancy is the result of two people, a male and a female. This quote would more appropriately read: "...we need to require MEN to choose responsible parenthood..."

Thank you, DHFabian. You have a good point. Men SHOULD choose responsible parenthood. CL

Re: "This quote would more appropriately read: "...we need to require MEN to choose responsible parenthood..."

This implies only men should choose responsible parenthood. How is this an improvement over implying only women should? And just exactly how do you REQUIRE either women or men to choose responsible parenthood?

What you are ignoring is that many young women want to get pregnant and will do so by hook or crook. Says Huffington Post’s Keli Goff:

“As recounted to me by multiple aides, staffers and ex-girlfriends of professional athletes, there are women who go to elaborate lengths to become pregnant by them. Poking holes in condoms is just the tip of the iceberg, no pun intended.”

“But the equally disturbing issue is that (Justin) Bieber’s accuser follows a long line of women who not only use their sexuality to get ahead, but their wombs. The act of becoming pregnant on purpose with the goal of landing financial security has become viewed as such a common practice that it is regularly joked about whenever stories like this become public. Bloggers, commenters, and commentators use language like ‘just became pregnant with eighteen years of security’ or ‘she just hit the lotto’ to describe women announced to be carrying the children of rich men, particularly men they were not in serious relationships with but will now be linked to, both personally and financially, for life.” http://malemattersusa.wordpress.com/2012/03/15/what-justin-bieber-and-gold-diggers-can-teach-us-about-feminism/

A young, uneducated woman who can't secure a job may decide that getting pregnant by a young man with a job is her ticket out of despair. Or she may find that having any man's baby is her way to welfare, which is often a step up for many poor people.

Nope, I never said men only. I pointed out that with rare exception, this generation puts not only 100% of the responsibility, but the blame on women. When we talk about single mothers, it's with contempt. When we talk about single fathers, it's with admiration. This generation's treatment of poor single mothers is purely punitive. That said, be careful with the sterilization discussion, considering the US 20th century record of forced sterilizations of those deemed something less than the rest of us.

I hate to say it since this is such a well-written and deeply-felt piece, but I think the central finding it is based on (like the paper it draws from) is mostly due to a cohort effect. From 1990 to 2008 the share of white women over 25 who completed high school went from 79% to around 88%. This means the group under study shrank by nearly half over those two decades. The reason is, essentially, that while the hs grad rate for white women stayed the same over those years, the oldest part of the cohort phased out into the next life - that older part having graduated in a time when hs graduation for women especially was less tethered to socioeconomic status. Basically, the patriarchal oppression of prior generations, which kept relatively higher socioeconmic status white women from completing hs, was fudging the stats, masking the difficult conditions of the bottom 10% from statistical view. Is it possible that things have gotten objectively worse for that bottom 10%? Sure. Do we know that from this data? No. The question we need to ask is "have conditions changed, for better or for worse, for a certain constant subset of the population over time?"

I think you nailed it on the cohort issue although I do not recall a lot of patriarchal oppression in 1990 . The change in the drop out rate would not only shrink the pool but leave it with those most likely to have some sort of significant disadvantage. It would include a growing share of those who were already unhealthy and thus performing poorly in school, those who were long term impoverished (and all of the disadvantages that come with that), and those inclined to make bad decisions (including drug and alcohol abuse). I feel sorry for the subject of the article but if you do not factor in the characteristics of the individuals who make up the pool then the question about conditions changing is somewhat moot.

I graduated high school in 1959 in the Deep South (Georgia). Was this not the pinnacle of "patriarchal oppression" (PO) in both time and place?

Well, let's see: my '59 year book shows that of the 63 who graduated, 29 were boys and 34 were girls. Oops, no sign of PO there.

Most of my teachers were women. Oops, no sign of PO there (just hiring discrimination against men).

The honor students, the grads with the best grades: three boys and ten girls. Oops, no sign of PO there.

The valedictorian was girl, as was the salutatorian. Oops, no sign of PO there.

Girls weren't drafted almost right out of high school back then. Oops, no sign of PO there. Only boys had the nightmares (as I did) of having to fight in a war and being killed or maimed, unless they had the resources to go to college or wanted to join the military.

Would someone please define in concrete terms the "patriarchal oppression." I will await your answer.

I also graduated high school in 1959 in the Upper Peninsula of Michigan a designated poverty area during the War on Poverty. My class had 125 students and the percentages were similar.

The guys didn't put in much effort because they didn't have to. They would get jobs or go into the military out of high school and get training for skilled work in the military or as an apprentice. Smart women had the option of teacher, nurse, librarian or secretary, all occupations that paid about half of a man's job requiring comparable skills.

At that time, there were two men enrolled in college for every woman. Abortion and contraception were contraband so women whose family didn't have money or connections were always at risk of unplanned pregnancy which was used to justify discrimination based on sex.

As for the old they-should-keep-their-legs-together canard, the average age for first marriage for women was 18 and for men 21 and 1 in 4 women was pregnant on her wedding day. The same states implementing this policy are the same one with the dropping life expectancies. Same attitude, same result. What a surprise.

I think you're missing that patriarchal oppression cuts both ways--it includes the lack of women in power and health care inequities as well as men being drafted and the whole restrictive "real man" masculine role. So in a way you answered your own challenge.

Also, professions where women congregate--teaching, social workers, nurses--tend to be vastly undervalued (as opposed to professions where men congregate, such as engineering or law). "Women's work" is nearly always paid less regardless of the fact that its vital for society. In fact, as a profession become feminized (think anthropologists) the pay tends to go down even if the work is the same. (sorry, just had to reply to that teacher comment).

I think you're missing that patriarchal oppression cuts both ways--it includes the lack of women in power and health care inequities as well as men being drafted and the whole restrictive "real man" masculine role. So in a way you answered your own challenge.

Also, professions where women congregate--teaching, social workers, nurses--tend to be vastly undervalued (as opposed to professions where men congregate, such as engineering or law). "Women's work" is nearly always paid less regardless of the fact that its vital for society. In fact, as a profession become feminized (think anthropologists) the pay tends to go down even if the work is the same. (sorry, just had to reply to that teacher comment).

Most of the males in my segregated high school in 1960 joined the military or got jobs that managed to support a family while the female worked next to the male for 50% of his income. That number has gone up to 77% with stiff opposition from the GOP to making equal pay for the job regardless of sex. At that time there was no good source of birth control and abortion was illegal. In the 1970's in California I was able as a married woman to obtain a credit card without my husband's signature. His debts that were unknown to me could not automatically be used by creditors against my salary. Child-support became easier to obtain from the ex-husband. Divorce rates rose and homes were harder to buy leaving many women of my age in poverty in their old age. It was a man's world despite men being used as cannon-fodder by the wealthy for hundreds of years. Yes, WWII was a good war. Since then we could have done without the military adventures and strengthened our own country. It was not until I read about "patriatchal oppression" that I realized I never had a chance to support myself like women do today. We are not going back to the old ways despite the red state draconian laws against women.

Are you asking if things have changed for the poor? Obviously, they're much worse of all age groups of the poor. Those who haven't yet lost everything are a single job loss from losing everything. Something middle classers don't get: You can't get a job without a home address, phone, bus fare. Overall, the US has shipped out the bulk of our manufacturing jobs since Reagan, and those were the jobs that were the path out of poverty for so many. As the US lost hundreds of thousands of jobs, Clinton increased the number of people absolutely desperate for jobs by taking an ax to welfare. More people desperate for fewer jobs. Poverty has increased, and severe (potentially life-threatening) poverty -- something that had become virtually non-existent in the US by 1980 -- has returned and is growing.

Most of these women used to be married and had family support. Now, they are the family support.

When an economy crashes, people die. All necessities for living become less especially when basics like food and health care are in short supply. During the past 40 years jobs disappeared, families fractured, communities dissolved and government support systems were no longer funded. Women traditionally have less ability to get out of poverty. Often they stay in their childhood locations partly due to support from their families and support they can give their children and their aging parents. The fictional nuclear family does not work for poor women. When economies are failing there is a rush by those with more assets to protect themselves from being around poverty. Perhaps when the agricultural community existed before WWII women could have survived with self-production of food, family and community support and the need for labor traditionally done by women. That life-style is long gone with nothing to replace it leaving uneducated poor women alone. The only surprise is that in a country as wealthy as the US it was so easy to watch them die.

In the modern era, those who were desperate could at least turn to welfare, receiving enough aid to keep them housed and fed until jobs came back. What became known as AFDC was actually written into FDR's Social Security Act of 1932. That was wiped out in 1996. The Depression Era taught Americans many lessons about both poverty and unrestrained corporate power -- lessons that were forgotten by the 1980s. Today, everyone is educated. But during my life time, we've gone from a point where a high school education was all that was needed. Now it takes a college degree to get out of poverty, which a huge segment of the population has no chance of being able to afford. Our manufacturing jobs were replaced with jobs requiring degrees, or dead-end service jobs, and there simply aren't enough service jobs to meet the employment needs of the people.

Are you kidding? What a load off bull! She died because she was lazy and FAT... I know that is not PC, but it is also not society or anyone else’s, but her fault. You do not need money to stay in normal physical shape. Many poor people went on to be the most outstanding athletes of their time. I feel sorry for the woman and many others like her, but there are too many excuses for her bad choices. Now everyone can attack me and the truth…

Sorry, you're wrong about the science of this though you are unfortunately aping conventional wisdom.

This is a scientific controversy but one with enormous public health implications. Though when
I say it is a controversy the evidence has been around for a while to settle it. Unfortunately
two things keep debate alive, one is institutional inertia and the second is the fact that the decisive
type of study you would need to convince all parties is seriously expensive but there is an effort under
way to raise the funding for this purpose.

There have been two basic theories of obesity developed over the 20th century, "caloric excess" and "dis-regulation".
They are the same theory except for the issue of causation so that one says
excess calories (too much food, too little exercise) causes the body to put on weight and the other that the arrow of
causation is reversed, fatty tissue controls our activity levels and appetite. In other words, the second theory
says, while you have to have excess calories to put on weight, the body doesn't automatically start putting on weight
just because the calories are available (and the biochemical evidence is pretty clear this is true).

Doctors get taught elements of both theories in med school but
aren't taught they are actually different and contradictory theories. What is strange
is that the caloric excess test doesn't stand a simple test of logic. Doctors
are taught excess calories make you heavier and they are taught insulin is
the master regulator of fat accumulation. You cannot get fatty acids into fat
cells without insulin and high insulin levels keep fat locked up so the body
cannot access its stored energy supplies.

So what the logic test? Fat is more caloric than protein or carbohydrates so
the calorie theory would say eating fat will make you heavier. However, what
is the effect of fat on insulin levels? Is it higher or lower than protein and carbs?
Well, actually the fat effect is lower, in fact, fat intake has zero (nada, zip) impact
on insulin levels. So the biochemically necessary mechanism for fat accumulation
is not affected by how many fat calories you eat. This science was worked
out in the 60's, in case you're wondering.

The disregulation theory states that under normal circumstances the body prefers a set weight and works hard to regulate it.
When, for whatever reason, fat tissue starts accumulating fatty acids the result is that the body reacts by increasing appetite and
adjust activity levels. The thing that most often throws this system out of whack is too much insulin in the body.
For most people, insulin imbalance is caused by too many carbs in the diet with sugar playing a long term role term by
causing damage to the endocrine system that makes the problem worse (this is what is known as Metabolic syndrome).
Btw, this is the connection to PCOS.

The thing is that the second theory actually conforms to the evidence (biochemically,
animal studies, anthropology, case history of long term dieting )
much better than the too many calories but for reasons stupid the excess calorie
theory became popular in the US after WWII. So in short , the second theory is the theory of
why low carb diets work (and they work spectacularly and are much easier to do, the evidence
is pretty clear on that). Doctors and people who enjoy being judgemental
just haven't caught up on the science.

Btw, this nutrition controversy is tied up with the idea saturated fats are bad for us.
The evidence linking fat in general (and saturated fat in particular) to heart disease
has always been very weak. Anyone says otherwise doesn't know the literature or
statistics. But the one thing that doctors were sure of when "saturated-fat
is bad" become the orthodoxy (due actually to the McGovern committee and
NIH in the late 70's, early 80's) was that heart disease was associated with
obesity. Now everyone in the controversy still agrees with that, it is
just that one side has the wrong theory of obesity.

I didn't catch how she was just lazy, although I do know that severe depression can wipe a person out (regardless of what the scolds say). You should know that obesity is a very complex issue, and is often not caused by eating excessively.

Obviously, poor people sick and dying for lack of resources is serious and deserves attention. So thank you for that. However, I want to point out the evidence in this story that the problem is getting worse is quite thin. Falling life expectancy could very well result from the decline in the size of this group - White women without high school degrees - with healthier people leaving sicker ones behind. Among White women, dropping out of high school is rare - about 5% - so they are a very select group. This fits with the fact that mortality is lower for Black women high school dropouts. When dropping out is more common, the group includes more healthy women. Changes in the composition of the group could account for this. I ran some numbers that seem to support my suspicion, and put up a few graphs here: http://familyinequality.wordpress.com/2013/09/04/are-white-women-high-school-dropouts-getting-sicker/

I know I am an evil person, but I found this article about a very serious subject utterly hilarious. By the time I got the part where Possum had a steel plate in his head and the only bar to marrying the teen you knock up is to promise never to hit her, I was laughing out loud. I am convinced the poor woman died of cliché. Arkansas should sue the author.

Food. It HAS to relate to all this somehow. I'm sure it's not any one simple answer, but our entire food system is corrupted. I've been doing some reading this summer, and it turns out that since the mid-1980s the FDA has basically been serving agri-business and big pharma--not the American public. All US milk products are tainted with growth hormones proven to do harm to both the cows and those who eat them. Thalates in plastic are similar to synthetic female hormones. BPA is also in plastics as well as lining most cans. Genetic modification in corn and soy (products that are in everything) can contribute to cancers and awaken "sleeping" bacteria and viruses in our gut as we digest them. These things have been proven, but just not made highly public. Canada and the European Union have been much slower than our FDA to OK these chemicals and GMOs and for good reason. I have read reports on scientific studies that have proven these things to be harmful--things that have totally infiltrated our food system. These studies have been swept under the carpet and not reported on by American journalists. We are being poisoned to death and no one cares so long as the bottom line of the multi-national corporations stays in the black. No one really knows what all these chemicals and GMOs are doing to us because there is not enough research being done. We are all human guinea pigs. Scientists knew in 1998 that the act of gene splitting, even of 2 different harmless substances, can cause very harmful results. The reason is that gene-splicing is NOT an exact science--it is a crapshoot. They don't really have any control over how the various proteins in the DNA will react when linked to the new proteins. And how can putting herbicides and pesticides INTO the food, where it can't be washed off, be deemed healthy for people to eat? It's not--yet the FDA approved it. Aspartame/Nutra-Sweet, the artificial sweetener in almost everything, is questionable, but was approved. It turns into wood alcohol and formaldehyde when digested. When heated above 80 degrees F, it becomes even more poisonous. Yet, the FDA also approved it to be used in things like jello and hot drinks. MSG, a flavor enhancer, can cause heart palpitations in people. All of these things NEED to be considered along with the social aspects discussed in this article. If nothing else, better educated, higher income folks are more likely to eat more healthfully, including eating more organically grown foods. This matters way more than the general public thinks! I am neither a reporter nor a scientist, but will someone please start doing more research on this stuff and going public with it? We are all being poisoned by the very organization that is supposed to protect us--all in the name of money.

What is killing poor white women? Opposition to freedom to form consensual human ecologies by sorting proponents of social theories into governments that test them.

The social sciences can't advance without experimental controls. This is because any search for causation will be countered with "Correlation doesn't imply causation." by opponents of a particular hypothesis that is supported by correlation in the absence of control groups. It is supremacist for the government to test its social theories on unwilling human subjects and doing so provides no useful data anyway since no experimental controls are allowed. So even if you were a megalomaniac bent on tormenting humans by testing your theories on them without their consent, you aren't going to get any further understanding of causal laws in human ecology than would a theocracy.

It is not compassionate deciding you have figured out what is killing these poor white women and then sending in government agencies to "fix" the situation.

The only relevant question for society is how we are going to sort proponents of social theories into governments that test them.

That is Sortocracy's Compassion.

We actually did make significant progress from the 1940s through to the 1980s, but middle classers resented it. Our "failed" welfare system -- particularly AFDC -- was actually very successful. It provided just enough economic stability to enable young parents to get on their feet, and to obtain medical care if needed, and education/training. Before "reform," some 80% of AFDC recipients were able to voluntarily quit welfare for work by the time their children started school. The measure of stability provided by welfare enabled many, many families to stay together, housed and fed, during periodic economic downturns Today, many of us are a single job loss from losing everything, with no way back up. How do you get a job without a home address, phone, bus fare?

You're a perfect example of what I'm talking about. The causal structures of human ecologies are complex just as they are in any ecology including, for example, the ecology of a single human body. In the case of single human body, we have a thing called "medical ethics" that keeps people like you from two things: 1) Applying "treatments" that have not been thoroughly tested with control groups to determine efficacy and safety, and 2) Conducting the tests on unwilling human subjects. The monstrosity of liberal democracy is that it is a tyranny of the majority limited only by a vague laundry list of selectively enforced "human rights" -- a monstrosity that arrogates to itself the right not only to apply treatments that haven't been put through rigorous controlled studied, but to do so to entire populations of unwilling human test subjects without so much as a control group. Your arrogant interpretation of the data would have you thrown out on your ear in the medical profession and possibly imprisoned. There are a vast number of reasonable hypotheses regarding the human ecology you have proclaimed to have "successfully" treated -- hypotheses including unintended side effects that are worse than the disease you claim to have "cured".

No, you can't make any claim to "progress" at all -- not even with mountains of supporting correlations that seem to support your idea of causation -- if you achieved your "success" on the backs of unwilling human subjects -- and that includes the people who paid the taxes for these programs as well as their supposed "beneficiaries".

I don't know "what's killing poor white women" in general, but what killed Crystal is almost certainly PCOS. I was pretty sure when the author wrote about her late miscarriages, and then really sure when I heard about the "cystic ovary" that was removed, and her untreated diabetes. PCOS causes all those things. A competent OB/GYN should have tested Crystal for a PCOS and several other disorders, including blood-clotting disorders such as Factor V Leiden and MTHFR, which are commonly found in women suffering from PCOS. If she had untreated PCOS and a clotting disorder, it is no surprise she did not make it to 40; the research is pretty clear what happens when women who have symptomatic PCOS do not get therapy. The bad news includes: 10x risk of heart disease, including sudden cardiac death. Most women - in some studies, it's over 80 percent - with PCOS are subsequently diagnosed with Type II diabetes within 10 years of their PCOS diagnosis. Average lifespan in one study was estimated to be shortened by 10-15 years.

What could Crystal have done? What could the few doctors she saw sporadically have done for her? Long-term therapy with Metformin and Spironolactone - my therapy regimen - can help a lot. Metformin treats insulin resistance that is found at a 4x higher incidence in PCOS women regardless of body mass. (BTW, for those who are saying "she could have just lost weight" - PCOS and its attenuated metabolic problems and insulin resistance makes weight loss on a "recommended" low-calorie, higher-carb diet nearly impossible.) Spironolactone treats androgen imbalances that cause high estrogen (itself a heart disease and cancer risk) and the "visible" symptoms - cystic ovaries, hirsutism, head hair loss. A low-carb diet is a must - Crystal's Dr. Pepper "addiction" worsened her symptoms, without question. Exercise helps. Most women on drug therapy who also incorporate exercise and dietary changes into their lifestyle are able to lose weight (not a lot - between 10% and 25% is average) and that helps the body rebalance itself. If that doesn't work, bariatric surgery can cause a near-complete remission of all symptoms. Any competent endocrinologist could have tested Crystal for PCOS, and then prescribed drugs and counseled her how to treat it in two office visits. The drugs Crystal needed are generic and at Wal-Mart would have cost her a grand total of - wait for it - $6 per month. But Crystal never got the chance to be treated, because no one ever suggested she should, or apparently referred her to an endocrinologist. And she wouldn't have been able to afford it if they had.

How do I know all of this? I was diagnosed with PCOS at 24 and had to learn a lot, really quickly, about how to manage the syndrome, because I didn't want to die young. I am Crystal - I just had health insurance, and was able to go to an endocrinologist, who got me a diagnosis, prescribed drugs, and helped me find nutrition counseling. I could afford to buy walking shoes and start walking, and then eventually join a gym. Since my diagnosis I haven't lost much weight, but it's stayed stable (something that almost never happens in untreated cases) and my health metrics (tested twice yearly) are all great - no diabetes, low-to-normal blood pressure, normal cholesterol, etc. I am alive because I could afford to go to the doctor and find out what was wrong with me, and get treatment for it. Crystal is dead because she could not afford health care. That's it, and that's all.

I was brought to tears by Crystal's story and hope that her daughter will watch for signs of PCOS (there is a familial connection) and also watch Crystal's granddaughter for signs, as she approaches puberty. I am so, so sorry this happened to Crystal and her family. If you suspect you have PCOS, please, get tested and get treatment. This is the unseen side of PCOS - behind the fat girls who can't lose weight, behind the women who can't get pregnant, behind the "bearded ladies" who are ashamed to leave the house, is this dark, lurking specter of early death. PCOS kills. It's time doctors started aggressively testing for it, and treating it.

@slaib: I appreciate many of your points regarding additives, gene manipulation, et al. ... This is one issue.

In my view, higher-educated, higher-income people are not, as a group, any more knowledgeable about good nutrition/health than anyone else. They are enthusiastic victims of junk science and food fashions. (And then are smug about it!) Next time you enter any "natural" food store, organic-intensive store or food co-op, look at how much prime retail real estate is populated by "natural" supplements and vitamins. (If your diet is so good, why do you need supplements?) Now go look at all of the "improved" water lined up in plastic bottles.

While we discuss the dangers of artificial additives and invasive technologies into our food streams, let's not default to the false belief that because something is "natural" it is good. What I mean to say is, let's not single out ingredients for demonization solely because they are artificial.

This is the kind of thing that makes me talk about white privilege in a different way these days (as one of many, many oppressive systems and only as a personal attack when someone is a racist d-bag. Regardless of your ethnic identity it's all about that paper y'all! (P.S. I from rural Arkansas, born and raised--hell, I even have a sister named Crystal. This article could be about any number of the women I grew up with.)

i come from a family that gets fat easily. i've peeled off 30-60 lbs many times in my life of 50+ years. Believe me, the issue is CALORIES. Restrict your calories, and i don't care what else you do, or are, or have, or do not have, YOU WILL LOSE WEIGHT. It is insanely simple. Look at concentration camp victims --- they ALL lose weight, regardless of what pre-existing conditions they had. That's because their calories were RESTRICTED. I have done the very-low carb diets. They were no magic wand. You can't just eat no carbs then pig out. You will gain weight. A few people here and there say that they can eat maybe a few hundred more calories per day if they eat almost no carbs. Possibly that is true, in some cases. HOWEVER, the issue REMAINS: Calorie restriction os the issue. Calorie restriction is 100% GUARANTEED to make you lose weight. Period. Cutting carbs cannot make this guarantee. Many want to blame the evil food corporations. Hogwash. They are doing their job, making food as tasty as possible. It is your job to not eat it. Just because a knife-maker makes a sharp knife doesn't mean you have to cut yourself. As for all of these complicated metabolic theories -- once again, WHO CARES? Just RESTRICT CALORIES, and you will lose weight, guaranteed, and most all of this metabolic stuff will clear up. And, yes, it's hard. And, yes, it is psychologically and emotionally painful -- sometimes quite difficult. Yep. That's correct. I like to say about dieting, "If it ain't hurtin', it ain't workin'" Pain is pathway to slimness. So many want to dodge that. They shouldn't if they want to be slim.

One other thing. Crystal was drinking Dr Pepper a lot. If she drank just 200 calories of Dr Pepper a day on top of her normal diet-- very easy to do -- in one year, she would gain 20 lbs! In five years, she would gain 100 pounds. And, take a look -- looks like 100 lbs to me, at least, It isn't soda that is bad. It isn't sugar that is bad. It is TOO MANY CALORIES that is bad. It is not complicated.

After reading all the comments, I believe that the author has written a clear presentation of an unfolding tragedy. Poverty, malnutrition, inadequate medical care, unemployment, substance abuse, and inadequate education all afflict this population. The rules that control access to money, food, jobs, medical care, housing, recreation, advanced education, and virtually everything else are set up by the haves, who continue to find ways to increase their own benefits, while denying them to the less fortunate. A prime example: the current battle over the Affordable Care Act. Those who continue to work to gut it offer no alternative for the millions whom they want to deprive of its benefits, like elimination of pre-existing conditions as a cause for denying health insurance.

I commend the author and cheer her efforts to spread the word and right the wrongs.

Ms. Potts, this is the kind of journalism that makes a difference in connecting the dots between individual lives and the broader social issues that impact diverse populations. You have done incredible work with this in-depth, explanatory piece. Thank you for such a well-written article.

I think it would be wise to look in the direction of advocacy and access to social services. Poor white women are largely ignored because too often race is used as proxy for low socioeconomic status, with that race being African American. Additionally, as many have already pointed out, its a man's world and women are largely disadvantaged. Given these two points - access to social services and advocacy for this access is directed largely toward African Americans in general and specifically AA women because they are a minority on two fronts. Alot of the comments I am reading seem to be neglecting that this trend is only showing for white women who are poor. This population is largely neglected in general becasue they are women and largely neglected in access to social services because they are white. A double whammy of sorts that MAY be impacting this early death trend

As an African American woman let me say I disagree with your statement. There aren't any social service program African Americans receives white women don't receive. To be frank, white women receive these services more than African American women. Since slavery black women always had to be the the head of the household due to the masters selling off our families. Til this day black women are the head of her family. Taking care of her children and elderly parents at the same time without help. Many times living in dangerous neighborhoods witnessing violence and drug abuse. The difference is black women have been trained by our mothers and grandmothers to stay close to God regardless of your circumstance. Don't look to anyone or anything but to God for your solutions. I would say that would be the reason maybe young white women are dying younger. They don't have that spiritual connection to God which is necessary to survive in this world. African American women are more religious than any other group in this country. So I would have to say that's why black women are living longer.

let's see xanax,vicoden etc.you ask your average poor white girl and they're better than a pdr.if the government wouldn't have made these meds so available you wouldn't be seeing this.pc is wonderful

Most Americans, including high-school dropouts of other races, are gaining life expectancy, just at different speeds. Absent a war, genocide, http://www.fraygame.com/ pandemic, or massive governmental collapse, drops in life expectancy are rare.

This article brought tears to my eyes. Growing up in Southeastern Ohio, a community riddled with poverty and lack of education, I've seen this scenario play itself out too many times. As women, we need to do better by our daughters. Education first, pregnancy and marriage can wait. This alone would change the lives of so many.

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