The High Infant Mortality Among Non-Hispanic White Infants in Appalachia: Is Whiteness a Factor?

Lively, Cathy

Photo by Sean Foster on Unsplash
The infant mortality rate in both Appalachia and the Delta is higher than in other parts of the US.[1] The Appalachian Region covers 428 counties in thirteen states. While Appalachia is economically disadvantaged,[2] the Delta is the most economically depressed area in the US.[3] The high infant mortality rate in both regions is under addressed and deserves closer attention and action. Certain aspects of white culture, including a distrust of government services, contribute to the stark infant mortality disparity among regions.
Although the US infant mortality rate decreased from 2017, 15 states and the District of Columbia had higher infant mortality rates than the national rate.[4] One 2017 study compared infant mortality in Appalachia with the rest of the US.[5] Although infant mortality declined across the US, the mortality rate was still 16 percent higher in Appalachia than in the rest of the US.[6] The researcher documented the relationship between poverty and infant mortality in Appalachia concluding that the disparities between Appalachia and the rest of the US would remain without corrective intervention.[7] The recommendations included an investment at various government levels, including increased access to high-quality, affordable healthcare.[8] The National Center for Health Statistics reported that for infants born to Hispanic and non-Hispanic black women, there was no notable difference in the infant mortality between the Delta and the rest of the US.[9] Infants born to non-Hispanic white women in the Delta and Appalachia had a higher mortality than the rest of the US.
The high infant mortality rate in Appalachia traces back to 1976. In 2012, the Journal of Rural Health published the results of research covering 1976-1980 and 1996-2000.[10] The research documented higher infant mortality rates in Appalachian counties. The research focused on white infant mortality based on the small number of infant deaths among other races in those counties.[11] The infant mortality disparity between Appalachian and non-Appalachian counties did not improve over the two decades of study. Race and culture might be the cause of the substantial difference between the infant mortality rate for non-Hispanic whites in the Delta and Appalachia compared to the rest of the US.
I. Poverty as a Cause
Several researchers document poverty as a contributory factor.[12] Poverty creates barriers in access to healthcare, education, and prenatal care.[13]  Yet, there must be something else. Research shows that areas with a majority black population reflect poorer health outcomes for all races. [14]  Appalachia, as reported in the Appalachian Region Census in May 2019, is overwhelming non-Hispanic white.[15] On that basis, race is not a factor.  The Delta and Appalachia “both have been hit hard by the epidemic of people addicted to opioid painkillers.”[16] West Virginia and Kentucky had the highest rates of drug abuse deaths in the nation.[17]  Yet, the National Center for Health Statistics did not include the opioid crisis as a cause of infant mortality.
II. Race and Class Politics
In “Dying of Whiteness”, Jonathan Metzl suggests a conservative movement purporting to make white America “great” actually harmed the lower and middle-income white individuals who supported conservative policies over the past decades.[18] The regions required investment at various levels of government.[19] The Delta Regional Authority (DRA) and the Appalachian Regional Commission (ARC) provide this assistance. The DRA and the ARC are a collaborative effort between governments at the federal, state, and local levels to address the needs of the respective communities. In 2017, President Trump's proposed budget eliminated funding for both programs.[20]
Metzl found that while wanting access to affordable care, many voters in Trump Country associate government intervention in healthcare with race and class politics.[21] This deep-rooted perception is linked to racism.[22] Despite the recognized need for affordable healthcare, many white residents of the southern states vehemently resisted Medicaid expansion. Metzl compared the opposition to the Affordable Care Act (ACA) in Tennessee to the opposition to the Civil Rights Bill of 1964, the national health insurance proposed in 1995, and the Johnson Administration’s creation of Medicare and Medicaid in 1965.[23]  In both eras, the misconceptions of non-white people’s use of government resources caused opposition from white people.
Strong spiritual belief, commitment to family, and community form the cultural fabric of Appalachia. [24] In Tennessee, many people are suspicious of elites and government even asserting “government or elitist interference of colonization.” Yet the expressed deep brand or corporate loyalty, family values, and community loyalty.  Historian C. Vann Woodward describes “the divided mind” of the South as mostly white men trying to participate in the economy and creating wealth but holding fast to prejudices not part of the more liberal states’ ethos.
The policies and sentiments found throughout the Delta and Appalachia bolster the identity of ‘whiteness,’ making whiteness a risk category.[25] The members of the affected communities who cling to entrenched dogmas are harming their own ability to access healthcare, better education, and the equal playing field that would allow for a more stable local economy. The recommendations suggested by various researchers will not be effective if the community rejects what it considers government or elitist interference.
III. Recommendation
The communities most impoverished must be educated in the spheres of policy and economics. The American tradition of many people in rural states voting against their economic interests causes the disconnect that prevents them from accessing healthcare and healthy lifestyles. An educational push should encourage civics to overcome prejudices and propel fact-based education. The stigma of government programs like SNAP and Medicaid in Appalachia and the Delta can be overcome. Infant mortality in a country as wealthy as the US is an unacceptable outcome.  By including family values, the values of hard work, paying one’s own way, and including religious outlets, the electorate can be pushed to educate people, possibly leading to reform.
In the Delta and Appalachia, family values and community belief systems prevent people from seeking the help needed to combat infant mortality. Access to healthcare, healthy food, good jobs, and strong educations can propel the regions to move toward economic safety. Leaving behind Trumpism, racism, and a distrust for government could be beneficial to the people. Poverty alone is not the cause. Policies, voting habits, and rhetoric that condemn the possible solutions as liberal or elitist cause the disconnect in infant mortality rates. Maintaining a values system that glorifies whiteness undermines success. Any approach will need to come from within the communities but should aim to destigmatize government assistance and improve education. Education to increase health literacy is crucial in areas where healthcare access is limited due to political choices. Merely providing information is insufficient.  A complex and integrated intervention can help transform cultural deeply held beliefs that harm the ability of the population to take steps to ensure healthy pregnancies and infants.
[1] Driscoll, A. K., & Ely, D. M. (n.d.). Maternal Characteristics and Infant Outcomes in Appalachia and the Delta. Maternal Characteristics and Infant Outcomes in Appalachia and the Delta (11th ed., Vol. 68). National Center for Health Statistics -National Vital Statistics Report.
[2] Singh, G. K., & Siahpush, M. (2014). Widening Rural–Urban Disparities in Life Expectancy, U.S., 1969–2009. American Journal of Preventive Medicine, 46(2). doi: 10.1016/j.amepre.2013.10.017; Appalachia Then and Now: Examining Changes to the Appalachian Region since 1965. (n.d.). Retrieved from
3 Driscoll, p. 1

[4]  Infant Mortality in the United States, 2017: Data from the Period Linked Birth/Infant Death File
[5] Singh, p. 1425
[6] Singh, p. 1425
[7] Singh, p. 1431
[8]  Singh, p. 1430
[9] Driscoll, p.8
[10] Yao, N., Matthews, S. A., & Hillemeier, M. M. (2011). White Infant Mortality in Appalachian States, 1976-1980 and 1996-2000: Changing Patterns and Persistent Disparities. The Journal of Rural Health, 28(2), 174–182. doi: 10.1111/j.1748-0361.2011.00385.x
[11]  Yao, p. 174.
[12] Eudy, R. L. (2008). Infant Mortality in the Lower Mississippi Delta: Geography, Poverty and Race. Maternal and Child Health Journal, 13(6), 806–813. doi: 10.1007/s10995-008-0311-y; Gortmaker, S. L. (1979). Poverty and Infant Mortality in the United States. American Sociological Review, 44(2), 280. doi: 10.2307/2094510 ;  Hillemeier, M. M., Lynch, J., Harper, S., Raghunathan, T., & Kaplan, G. A. (2003). Relative or Absolute Standards for Child Poverty: A State-Level Analysis of Infant and Child Mortality. American Journal of Public Health, 93(4), 652–657. doi: 10.2105/ajph.93.4.652; Singh, Supra.
[13] Eudy, R. L. (2008). Infant Mortality in the Lower Mississippi Delta: Geography, Poverty and Race. Maternal and Child Health Journal, 13(6), 806–813. doi: 10.1007/s10995-008-0311-y
[14] Coughlin, S. S., Thompson, T. D., Seeff, L., Richards, T., & Stallings, F. (2002). Breast, cervical and colorectal carcinoma screening in a demographically defined region of the US. Cancer, 95, 2211–2222.; Laveist, T. A. (2003). Racial Segregation and Longevity among African Americans: An Individual-Level Analysis. Health Services Research, 38(6p2), 1719–1734. doi: 10.1111/j.1475-6773.2003.00199.x
[15] The Appalachian Region: A Data Overview from the 2013-2017 ... (n.d.). Retrieved from, May 2019,
[16]  Chia, A. E. (2019, May 22). A Closer look at infant mortality rates in two of the most impoverished U.S, region. The Washington Post.
[17] Singh, Supra.    ; Chia, A. E. (2019, May 22). A Closer look at infant mortality rates in two of the most impoverished U.S, region. The Washington Post.
Singh GK, Siahpush M.Widening socioeconomic inequalities in US life expectancy, 1980–2000. Int J Epidemiol. 2006;35(4):969–79.
[18] Metzl   p.16 Metzl, Jonathan, M. (2020). Dying of Whiteness: how the politics of racial resentment is killing America’s heartland. S.l.: BASIC BOOKS.
[19] Singh GK, Siahpush M.Widening socioeconomic inequalities in US life expectancy, 1980–2000. Int J Epidemiol. 2006;35(4):969–79.
[20] McGill, B. (2017, May 22). Programs in Trump Country Stand to Lose Much in Budget Cuts. Wall Street Journal.
[21] Metzl  p.84
[22]  Metzl   p.16
[23] Metzl p.18
[24] Mental Health Disparities: Appalachian People - (n.d.). Retrieved from Library/Psychiatrists/Cultural-Competency/Mental-Health-Disparities/Mental-Health-Facts-for-Appalachian-People.pdf.
[25] Metzl, Supra.


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Voices in Bioethics

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August 19, 2022


poverty, Appalachia, partisan politics, infant mortality, bioethics