Behind the Uniform: Prevalence and Determinants of Alcohol Use Disorder in the Tunisian Military.

Over much of the past century, high-income countries have experienced remarkable gains in life expectancy, largely due to improvements in healthcare, living standards, and public health interventions (). Yet, in the mid-2010s, this long-standing trend began to falter. Although most high-income nations quickly resumed the trend of increasing life expectancy, the United States (US) and the United Kingdom (UK) emerged as notable exceptions. Economists Anne , , ) identified a key factor behind declining US life expectancy: increasing rates of death among non-Hispanic white Americans aged 45–54 from drug, suicide, and alcohol specific mortality. termed deaths from these causes ‘deaths of despair’ (DoD) and proposed that long-term shifts in social structures and labour market conditions, such as delayed marriage, increased childcare demands, limited educational opportunities, stagnant wages, and rising housing costs had created cumulative disadvantage over successive generations, fostering widespread despair that ultimately contributed to increasing rates of DoD. Case and Deaton’s (2020) proposition that DoD share a common underlying cause has been the subject of ongoing debate (; ; ; ). Nonetheless, their work has significantly influenced both academic discussions and media coverage. The term ‘deaths of despair’ is now widely used in scholarly articles and news reports (; ; ; ; ; ). Initially thought to be a uniquely American issue, rising rates of DoD have also attracted research attention in the UK (; ; ; ; ). Although DoD only partially explain the stalling life expectancy in the UK prior to the COVID-19 pandemic (), there has been a notable rise in DoD rates in the UK since the early 2000s (). Much of this increase has been driven by increases in drug-related mortality, with deaths from suicides and alcohol-specific causes increasing at a more moderate rate (; ). The existing literature from both the US and UK surrounding the factors underlying increasing rates of DoD has found an association with structural determinants such as welfare, housing, and labour market policies (; ; ). There are also clear associations between increased rates of DoD, poverty and economic decline with deaths from these causes concentrating in deindustrialised, low-income communities in England (; ) and other national contexts, such as the US (; ) and Eastern Europe (; ). There are significant geographic inequalities in rates of DoD within the UK; for example, Scotland has a significantly higher rates of DoD than other constituent countries (; ). Within England, geographic inequalities in rates of DoD persist between regions and cities and towns within regions (; ). In the North East, the English region with the highest rates of DoD, two local authorities, Middlesbrough and South Tyneside have significantly higher than regional and national average rates of DoD (, , ). These geographic patterns reflect broader social and economic inequalities that are deeply embedded and are produced and sustained through a combination of structural and social determinants (). Understanding why these inequalities persist requires not only examining material conditions but also considering how cultural forces shape perceptions of health inequality. One concept that offers valuable insight into this process is Pierre Bourdieu’s theory of symbolic violence ().