August 8, 2017

A new study co-authored by a UNC Gillings School of Global Public Health researcher confirms a widening gap in health equity between Appalachia and the rest of the United States.

Dr. Becky Slifkin

Dr. Becky Slifkin

Rebecca Slifkin, PhD, clinical associate professor of health policy and management at the Gillings School and associate chair of the department, is last author of the study, which was published online Aug. 7 in the journal Health Affairs.

Using data from the National Vital Statistics System, the study authors compared infant mortality and life expectancy in Appalachia, a disadvantaged region that runs from Mississippi to New York, to those outside the region, for the period between 1990 and 2013.

Despite national improvement in both infant mortality and life expectancy, disparity between Appalachia and the rest of the United States increased over the time period studied. The authors found that infant mortality, which was essentially the same in 1990, was 16 percent higher in Appalachia in the 2009-2013 time period. Disparity in life expectancy also increased; while the average life expectancy in Appalachia was 0.6 years less than the rest of the U.S. in 1990-1992, the deficit increased to 2.4 years in 2009-2013.

The disparity in life expectancy was greatest among white men. In the period 2009-2013, white men were expected to live 74.5 years in Appalachia, and 2.6 years longer elsewhere. Mortality by any cause was 5 percent higher in 1990-1992, and 18 percent higher in 2009-2013, compared to the rest of the U.S.

In 2009-2013, infants in Appalachia, compared to elsewhere in the U.S., were 8 percent more likely to die from perinatal conditions, 12 percent more likely to die from birth defects and 61 percent more likely to die from sudden infant death syndrome (SIDS).

Between 1990 and 2009, much of the higher-than-average mortality in Appalachia was accounted for by people ages 65 and older. However, in the period between 2009 and 2013, almost half of the gap in life expectancy (48.6 percent) was due to the deaths of people ages 25 to 64.

Given a continuing gap in socio-economic and living conditions between U.S. population groups and regions, Slifkin and colleagues call for changes in policy and a commitment to improve the living conditions of people in Appalachia and other economically depressed regions.

They note that higher suicide rates may be the result of “social isolation, joblessness, psychological distress and other mental health disorders.” There is evidence that people in rural areas are more accepting of tobacco use and less likely to favor smoke-free policies in the workplace, home or public spaces. Lower accessibility of grocery stores is associated with higher rates of obesity and diabetes.

Motor vehicle deaths, which account for 30 percent of deaths from unintentional injuries, happen in greater numbers because of lower rates of seat belt use, longer driving distances between rural communities, and impaired driving from alcohol. Opioid and other drug use also contributes to the higher mortality from unintentional injuries.

Also important is the fact that when people do get sick, they cannot access care because of a shortage of doctors, high poverty, or because they are without transportation or too elderly to travel great distances.

“Given the national gains in life expectancy, seeing the increasing disparity between Appalachia and the rest of the United States should serve as a wake-up call,” Slifkin said. “Many of the reasons for the disparities we observe are due to differences in social determinants of health. We really need new investments to ensure that health is not determined by where one lives. As a society, we invest huge sums in medical care to extend an individual’s life; imagine the gains we could make if similar resources were devoted to public health.”

Slifkin’s co-authors are Gopal K. Singh, PhD, senior health equity adviser in the Office of Health Equity at the Health Resources and Services Administration (HRSA) in the U.S. Department of Health and Human Services, and Michael D. Kogan, PhD, director of the Office of Epidemiology and Research in HRSA’s Maternal and Child Health Bureau.


Gillings School of Global Public Health contact: David Pesci, director of communications, (919) 962-2600 or

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