The health crisis in rural America that has received the most attention in recent years is the epidemic of opioid abuse, a contributor to a rise in the mortality rate for middle-aged white people. But drug overdoses accounted for a relatively small amount of the life expectancy gap between health in rural Appalachia and the rest of the country, at least through the end of the study in 2013.

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In the early 1990s, health in Appalachian communities was far closer to national averages. Infant mortality was not significantly different from the rest of the United States, the researchers found. People in Appalachia could expect to live shorter lives, but the gap was small — about seven months shorter, on average than counterparts in the rest of the country.

The country made gains on those health measures over the next two decades, but progress in Appalachia stalled. Between 2009 and 2013, the infant-mortality rate was 16 percent higher in Appalachia than in the rest of the country. People could expect to live 2.4 years less than their counterparts in the rest of the United States.

“What was surprising was that in the early 1990s, there wasn’t a great deal of difference in infant mortality and life expectancy,” said Gopal Singh, a senior health equity adviser at the federal Health Resources and Services Administration, and a co-author of the study published in Health Affairs. But as infant mortality and life expectancy improved in the U.S. broadly, “the improvements have not been as rapid in Appalachia.”

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The study underscores the kinds of health disparities that exist within the United States — at a time that the country's overall performance on health measures has become a topic of growing concern. Studies have shown that infant mortality and life expectancy are worse in the United States than in other developed nations. The new data add another layer to that, highlighting the fact that some regions of the United States are even worse off than national averages suggest.

Kimberly Farry, an obstetrician and gynecologist who practices at WVU Medicine in Buckhannon, W.Va., said that it is not uncommon for her patients to drive two hours for an appointment, as maternal wards have closed at rural hospitals. In her career, she has seen her patient mix tilt toward higher-risk mothers with medical conditions such as obesity, high blood pressure and other factors. About one in every five of her patients is using some sort of drug that increases the risk to their infants' health — opioids, marijuana, alcohol, or simply the drugs used to treat opioid dependence.

“The number of physicians available, and the number of places available for patients to come for care has tremendously decreased,” Farry said.

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According to the study, drug overdose accounted for a little over 6 percent of the life expectancy gap between 2009 and 2013. The authors said that was an increase over the previous four years, but stressed that when new data is available for later years, it will be critical to extend the analysis to see how the growth in opioid use has affected the gap.

Unintentional injuries was one of the leading causes of death, and it includes drug overdoses. But nearly a third of the unintentional injuries were car accidents, so in addition to tackling the opioid epidemic, public health interventions that increase seat belt use or reduce drunken driving and speeding might help increase life expectancy.

Meanwhile, smoking-related diseases accounted for more than half the gap in life expectancy between Appalachia and the rest of the country.

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“The results are heartbreaking, but not unsurprising,” said Wendy Wasserman, a spokeswoman for the Appalachian Regional Commission, a regional economic development agency. “We're really interested in creating a healthy workforce, and all aspects of health are important to that.”

The biggest gap the researchers found in their data was a 13-year gap in how long black men in the most impoverished areas of Appalachia could expect to live, compared to white women in areas of the United States with little poverty.

The data do not reveal what has caused the health disparities to widen, but it does provide hints. Smoking and obesity are major contributors to poor life expectancy in Appalachia, for example, and the region is short on needed health-care services, such as primary care doctors. Many of the health-care factors are interwoven with economic circumstances.

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A factor the authors could not account for was the possibility that the region's health outlook is getting worse simply because healthier and younger people aren't sticking around. Appalachia has experienced slower population growth than the rest of the country, partially caused by young people leaving the region.

“We can’t really single out one factor that would be causing the difference between Appalachia and non-Appalachia,” said Micheal Kogan, director of the Office of Epidemiology and Research at the Health Resources and Services Administration's Maternal and Child Health Bureau. “It’s really a very diverse set of circumstances.”