Why understanding despair must be a part of our health care system

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A couple of years ago, I was grading final exams for a class on global health when I came upon a very fine essay, but one that did not answer the question I had actually asked. I asked the student to visit my office so I could understand why he had written what he had. After some hedging, he said that he did not have any clue how to answer the question on the exam, so he figured his best shot was to compose a solid essay on a related topic that he knew well. I secretly admired his ingenuity.

Today, something similar is happening in health care, but I fear it is less intentional than my student’s behavior—and the consequences are much more serious.


The suicide rate in the United States jumped by more than 20 percent in one decade, from 10.9 deaths per 100,000 people in 2005 to 13.3 deaths in 2015. Alcohol-related deaths have recently reached a 35-year high. And drug overdose deaths continue to climb at alarming rates despite national attention to the opioid crisis.

When students and parishioners seek counsel, I must determine whether I can provide adequate care or must refer them to another kind of professional.

In general, we see these tragedies as matters of medicine and public health. But that is only part of the story. A small but growing segment of the health care world has started to describe these and similar conditions as “diseases of despair.” This idea suggests that some of the major drivers of substance abuse, suicide and even certain chronic physical conditions are hopelessness, an absence of opportunity and unrealized desires for belonging.

It is understandable that many actors in the health care system do not consider despair to be a driving factor of these medical conditions. Much like my student, who knew he could not accurately answer the exam question, practitioners are not always well equipped to deal with matters of hope and belonging. So they respond to what they do know: the medical aspects of the disease. There is nothing inherently wrong with this. It only becomes a problem if the institutions that can help to ask and answer existential questions are sidelined or fail to contribute their expertise.

As a priest, I often face the flip side of this coin. When students and parishioners seek counsel, I must determine whether I can provide adequate care or must refer them to another kind of professional. I fail them if I pretend a psychological or medical issue can be solved with spiritual direction or pastoral care. The same is true when we accept systems that suggest there are medical solutions for existential and social crises.

Diseases of despair can affect anyone, but we must pay particular attention to the marginalized groups who are the most affected.

Diseases of despair can affect anyone, but we must pay particular attention to the marginalized groups who are the most affected. People with a disability are at least twice as likely to have a substance abuse disorder as the non-disabled. L.G.B.T. youth and military veterans commit suicide at higher rates than their heterosexual and civilian counterparts. Native Americans have the highest rate of heavy alcohol use of any ethnic group in the United States. The litany of those who suffer the most is sadly predictable, and one of the primary reasons is that they are given fewer reasons to hope, see less opportunity and are denied a sense of belonging.

Effective medical and public health interventions are necessary to solve diseases of despair. We must promote medication-assisted treatment and change physicians’ prescribing behaviors for opioids. We must properly fund mental health care and reduce access to means used for suicide, especially guns. But every health condition does not have a medical solution.

In order to effectively fight these diseases and help people lead flourishing lives, we must also begin asking better questions. Questions of why opportunity is not distributed equally across our society. Questions of what form community and belonging take in the modern world. Questions of how to communicate hope in a way that is believable. If we take these questions seriously, the diseases will not disappear entirely, but they will no longer be driven by despair.

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