Source: Thinkstock

41. Oglala Lakota County, South Dakota

> 5-yr. population change: N/A

> Nov. unemployment rate: N/A

> Poverty rate: 53.9%

> Life expectancy at birth: 66.8 years

American Indians living on reservations frequently reservations frequently struggle with lagging economic conditions and poor health outcomes. Perhaps nowhere is this more evident than in Oglala Lakota County, which is contained entirely within the Pine Ridge Indian Reservation in South Dakota. The median household income in the county of $26,330 is less than half what the typical household in the state earns annually. Additionally, 53.9% of the county’s population lives in poverty, the highest rate for any county in the nation.

The stresses and challenges that accompany poverty often take a toll on personal health. Not only is Oglala Lakota the poorest county in the United States. Its residents are also the least healthy. Life expectancy in Oglala Lakota is only 66.8 years, the lowest for any U.S. county and roughly in line with life expectancy in countries like Kenya or Rwanda.

Source: Brent Moore / Flickr

42. Grundy County, Tennessee

> 5-yr. population change: -2.3%

> Nov. unemployment rate: 4.6%

> Poverty rate: 28.0%

> Life expectancy at birth: 72.5 years

The typical household in Grundy County earns $28,467 a year, about $18,000 less than the median household income for Tennessee as a whole. Additionally, 28.0% of the county’s population lives in poverty, a rate that’s far higher than the state’s figure of 15.8%. One factor contributing to low incomes may be low educational attainment. Just 11% of Grundy County adults have a bachelor’s degree, representing one of the lower rates for counties in Tennessee and the country as a whole.

Income and education are two of the primary factors that influence health and longevity. The life expectancy in Grundy County is just 72.5 years, lower than the U.S. average of 79.1 and the averages for countries such as Sri Lanka, Saudi Arabia, and Honduras.

Source: U.S. Department of Agriculture / Flickr

43. Zavala County, Texas

> 5-yr. population change: +3.5%

> Nov. unemployment rate: 9.1%

> Poverty rate: 35.8%

> Life expectancy at birth: 77.9 years

For the vast majority of Americans, a high school education can serve as a foundation for building a healthy, financially stable life. In Zavala County — much of which is located within 20 miles of the U.S.-Mexico border — only 59.2% of adults have a high school diploma. This is one of the smallest shares of any U.S. county. Students who speak English as a second language can face additional challenges in school, and in Zavala County 93.3% of the population identifies as Hispanic or Latino, a larger percentage than in all but five other U.S. counties.

More often than not, better educated populations report higher incomes. Along with having low levels of educational attainment, Zavala County’s residents have a median household income of $26,639; this is less than half of what the typical household in the state takes in.

Source: Ken Lund / Flickr

44. San Juan County, Utah

> 5-yr. population change: +7.0%

> Nov. unemployment rate: 5.6%

> Poverty rate: 27.6%

> Life expectancy at birth: 79.0 years

About 47% of the population of San Juan County is American Indian. After decades of poor treatment by the government and racial discrimination, Native Americans are struggling with serious obstacles to financial stability, health, and prosperity. At the end of 2017, a federal judge ruled that the county’s commission map unconstitutionally grouped the entire Navajo population into a single district, despite the tribe’s accounting for about half of the county’s population. This could have an impact on the area’s poor living conditions — parts of the reservation lack electricity, running water, and other amenities under the purview of the county. Currently, 27.6% of the county’s population live in poverty, the largest share of any county in Utah.

Source: Adam / Flickr

45. Orleans County, Vermont

> 5-yr. population change: -0.6%

> Nov. unemployment rate: 4.0%

> Poverty rate: 14.6%

> Life expectancy at birth: 79.4 years

Orleans County is one of three counties in Vermont that comprise the Northeast Kingdom, a region known for its dairy farms and spruce, fir, and northern hardwood forests — but also its severe economic problems. The unemployment rate in Orleans County is 4.0%, the highest of any county in Vermont other than neighboring Essex County. An estimated 14.6% of residents live in poverty, also the second highest poverty rate in the state.

While Vermont has one of the highest life expectancies of any state, health outcomes vary throughout the state. The average resident born in Orleans County is projected to live 79.4 years, roughly 11 months less than Vermont’s average.