Racial, Ethnic and
Socioeconomic Health
Disparities in the US
Richard Lichtenstein Ph.D., MPH
University of Michigan
School of Public Health
June, 2010
Why is the health status of
African Americans worse than
the health status of Caucasian
Americans?
Health Status is a Function of:
•
•
•
•
•
Biology/Genetics
Lifestyle/Behavior
Social/Societal Characteristics
Physical Environment (“Total Ecology”)
Medical Care
Tarlov, A.R. “Public Policy Frameworks for Improving Population Health.” Annals of the New
York Academy of Sciences 896:281-293 (1999)
Impact of Various Domains on Early Deaths
in a Population
Medical Care
10%
Genetics
30%
Behavioral
Patterns
40%
Social
Circumstances
15%
Environment
5%
Source
McGinnis, et al, Health
Affairs 21: 78.
March/April 2002
A major area of research on
Health Disparities today is called:
THE SOCIAL
DETERMINANTS OF HEALTH
(SDOH)
GENERAL MODEL OF SOCIAL DETERMINANTS
Social Factors
Personal Factors
Access to Services
Individual risk factors
Quality of living area
Discrimination
Stress
Adoption of Preventive
Behavior
Outcomes
Disease
Health
Self Regulation/
Management
Social Support
Fundamental Factors: Money, Power, Prestige
CUES, NYAM, 2000
Diagram by Whitehead M and Dahlgren C, in “What can be done about inequities and
health?”, The Lancet, 338, 8774, 26 October 1991, 1059-1063.
Poverty is the Major Factor
in Health Disparities
Which Racial or Ethnic Group
Accounts for the Most
People in Poverty in the US?
Number of Persons Below Poverty Level By
Race, 2007
In Thousands
40,000
30,000
20,000
10,000
0
All races
White
Black
Source: Health, United States, 2009, Table 3
Asian
Hispanic
Percent below poverty
Percent of Persons Below Poverty Level By
Race, 2007
Source: Health, United States, 2009, Table 3
Why is there a relationship
between socioeconomic status
and race?
What is Race?
What is Race?
• Race is not a biological determinant
• “Race is a social construct, a social
classification based on phenotype, that
governs the distribution of risks and
opportunities in our race-conscious
society.”
Camara Phyllis Jones, Am J Epidemiol, 154: 299-304 (2001)
What is Race?
• “Although ethnicity reflects cultural
heritage, race measures a societally imposed
identity and consequent exposure to the
societal constraints associated with that
particular identity.”
Camara Phyllis Jones
Race Varies by Country
• “This assigned race varies among countries…In the
United States I am clearly labeled Black, while in
Brazil I would be just as clearly labeled White and in
South Africa I would be clearly labeled "colored." It is
likely that, if I stayed long enough in any one of these
settings, my health profile would become that of the
group to which I had been assigned, even though I
would have the same genetic endowment in all three
settings.”
Camara Phyllis Jones
Beware of treating Race and
Ethnicity as Monolithic Concepts
• Is everyone who is black poor?
• Do all Latino sub-groups
experience the same degree of
unequal health compared to
whites?
What are Health Disparities?
Health Disparities or Health
Inequalities are inequities that
are related to differences in
health status or medical
treatment that are unfair to
disadvantaged people and that
are avoidable
Braverman and Tarimo, Soc Sci and Med:54:1621-1635 (2002).
“Pursuing equity in health care means
striving to reduce avoidable disparities in
physical and psychological well-being—
and in the determinants of that wellbeing—that are systematically observed
between groups of people with different
levels of underlying social privilege, i.e.,
wealth, power or prestige.”
Braverman and Tarimo, Soc Sci and Med:54:1621-1635 (2002).
Demographic and Health
Characteristics of People on the
Eastside of Detroit
Table 1: Socio-Demographic Characteristics of
Eastside and Central Detroit in Comparison to City of
Detroit and the National Average
Source: 1U.S. Bureau of the Census, 2006-2008 American Community Survey 3-Year Estimates
2Detroit
data from www.CHIMart.org, 1999-2001 data
Table II: Health Status Characteristics of the
Eastside in Comparison to the City of Detroit and the
U.S. Population
Detroit data from www.CHIMart.org, 1999-2001 data
*2006 Data from Health, United States, 2009 Table 26
**Infant deaths/1000 live births, Health, United States, 2009, Table 19
Health Disparities
Life Expectancy at Birth
by Race and Sex, 1970-2006
85
White Male
80
Years
75
White Female
70
65
Black Male
60
Source: Health, United States, 2009, Table 24
2006
2004
2002
2000
1998
1996
1994
1992
1990
1980
1970
55
Black Female
Age-Adjusted Death Rate
Age-Adjusted Death Rates
Due to All Causes,
by Race and Hispanic Origin, 2006
1200
1000
800
600
400
200
0
White
Black
Am. Indian or Alaskan
Source: Health, United States, 2009, Table 25
Asian/Pacific Islander
Hispanic
Age-adjusted Death Rates
by Race, 2006
350
Deaths per 100,000
300
250
Disease of Heart
Ischemic Heart Disease
200
Cerebrovascular Disease
150
Prostate Cancer
Breast Cancer
100
Diabetes Mellitus
Homicide
50
0
All Race & Sex
White
Source: Health, United States, 2009, Table 26
Black
Native American Death Rates Compared to All Races
New York Times, December 2, 2009
YEARS OF POTENTIAL LIFE
LOST
Years of Potential Life Lost
due to Ischemic Heart Disease,
by race and Hispanic origin, 2006
White
Black
Am. Indian or Alaskan
Asian/Pacific Islander
Hispanic
1200
1000
Years lost*
800
600
400
200
0
2006
Source: Health, United States, 2009, Table 27
* Age-adjusted years lost before age 75 per
100,000 population under 75 years of age.
Years of Potential Life Lost
due to Diabetes Mellitus,
by race and Hispanic origin, 2006
White
Black
Am. Indian or Alaskan
Asian/Pacific Islander
Hispanic
Years lost*
400
300
200
100
0
2006
Source: Health, United States, 2009, Table 27
* Age-adjusted years lost before age 75 per
100,000 population under 75 years of age.
Years of Potential Life Lost
due to Homicide,
by race and Hispanic origin, 2006
White
Black
Am. Indian or Alaskan
Asian/Pacific Islander
Hispanic
Years lost*
1000
800
600
400
200
0
2006
Source: Health, United States, 2009, Table 27
* Age-adjusted years lost before age 75 per
100,000 population under 75 years of age.
5 Year Relative Survival Rates
for Breast Cancer
Percent of Patients (%)
100
White Female
90
80
70
Black Female
60
50
1974-79
1980-82
1983-85
Source: Health, United States, 2009, Table 50
1986-88
1989-91
1992-94 1996-1998 1999-2005
Infant Mortality Rates by Race*
United States, 1970-2006
40
All races
White
Deaths per 1,000 Live
Births
30
Black
20
10
1970
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
0
Source: Health, United States, 2009, Table 19
*Race of mother
Infant mortality rates by detailed race and Hispanic origin of mother:
United States, 2005
White, not Hispanic
Black, not Hispanic
Hispanic (total)
Puerto Rican
Other Hispanic
Mexican
Central and South American
Cuban
Asian or Pacific Islander (total)
American Indian or Alaska
Native
0
2
4
6
8
10
12
14
Infant per 1,000 live
births
NOTES:
16
Infant is defined as under 1 year of age. Persons of
Hispanic origin may be of any race. The race groups, Asian or
Pacific Islander and American Indian or Alaska Native, include
persons of Hispanic and non-Hispanic origin. See Data Table for
data points graphed and additional notes.
Centers for Disease Control and Prevention, National Center for Health Statistics. Health, United States, 2009
Infant Mortality Rate by Race (of
mother), 2001-2006
Infant Mortality Rate
25
20
15
White
10
Black
5
0
1980
1985
1990
1995
2000
2003
2005
2006
IMR: Deaths of infants under 1 year per 1,000 live births
Source: Health, United States, 2009, Table 19
International Rankings for Infant Mortality
1960 and 2006
1960
2006
Hong Kong
26
1
Singapore
21
Japan
1960
2006
Netherlands
2
17
2
Australia
5
20
19
2
England and Wales
9
21
Finland
6
4
New Zealand
10
23
Norway
3
6
Scotland
13
19
Czech Republic
4
7
Portugal
35
7
Canada
15
-
Belgium
11
-
Cuba
23
24
Austria
24
9
Hungary
31
25
Greece
25
10
Northern Ireland
14
22
Ireland
18
10
Poland
32
26
Germany
22
12
United States
12
28
France
16
12
Slovakia
17
27
Spain
28
12
Chile
36
29
8
12
Puerto Rico
27
-
20
16
Costa Rica
35
30
7
17
Russian Federation
---
31
27
-
Bulgaria
30
-
Romania
36
32
Denmark
Israel
Switzerland
Italy
Source: Health, United States, 2009, Table 22
IMR - International Rankings 2009
Country
Infant Mortality Rate
(deaths/1000 live births)
Rank
Angola
180.21
1
Afghanistan
153.14
2
Liberia
138.24
3
Niger
116.66
4
Mali
115.86
5
--
--
--
United States
6.22
180
--
--
--
France
3.33
217
Iceland
3.23
218
Macau
3.22
219
Hong Kong
2.92
220
Japan
2.79
221
Sweden
2.75
222
Bermuda
2.46
223
Singapore
2.31
Source: CIA – The World Factbook: (accessed May 14, 2010)
224
Infant Mortality Rates by mother’s education, race,
and Hispanic origin, 2003-2005
White, non-Hispanic
Hispanic
Asian or Pacific Islander
Black, non-Hispanic
American Indian or Alaska Native
15
IMR
12
9
6
3
0
Less than 12 years
12 years
Years of Education
Source: Health, United States, 2008, Table 19
13+ years
Low Birth Weight* by Race and
Ancestry of Mother, 2007
*less than 2500 grams
City of Detroit
Wayne County
Wayne County Health Dept.
Michigan
Percent Low Birth
Weight Births
16
12
8
4
0
White
Black
Arab Ancestry
Hispanic
Ancestry
Source: Division for Vital Records and Health Statistics, Michigan Department of Community
Health, 2007
Activities of Daily Living (ADL) and
Instrumental ADL (2008)
<$35,000
$35,000-$49,999
$50,000-$74,999
$75,000-$99,999
Percentage 18+ yrs Experiencing
Impairment
8
7
6
5
4
3
2
1
0
ADL
Source: National Health Interview Survey, 2008
IADL
$100,000 or more
Percent with Fair or Poor Self-Rated
Health Status, 2007
Non-Metropolitan
Metropolitan
Female
Male
65+
<18 years
Non-Poor
Near-Poor
Poor
Black
White
Total
0
5
10
15
Percent
Source: Health, United States, 2009, Table 57
20
25
30
Fair or Poor Health among Adults
18 years and older by family income, race,
and Hispanic origin, 2007
Poor
Near Poor
Non-Poor
25
Percent
20
15
10
5
0
White, non-Hispanic
Black, non-Hispanic
Source: Health, United States, 2009, Table 57
Hispanic
For Want of a Dentist
Pr. George's Boy Dies After Bacteria From Tooth Spread to Brain
By Mary Otto
Washington Post Staff Writer
Wednesday, February 28, 2007; Page B01
Twelve-year-old Deamonte Driver died of a toothache
Sunday.
A routine, $80 tooth extraction might have saved him.
If his mother had been insured.
If his family had not lost its Medicaid.
If Medicaid dentists weren't so hard to find.
If his mother hadn't been focused on getting a dentist for his brother, who had six rotted teeth.
Deamonte's death and the ultimate cost of his care, which could total more than $250,000, underscore an
often-overlooked concern in the debate over universal health coverage: dental care.
Utilization of Services
Health Insurance is important to Access,
but it is not the only factor
Percent uninsured
No Health Insurance Coverage among persons
under 65, by race and Hispanic origin, 2004
40
35
30
25
20
15
10
5
0
White, nonHispanic
Black, nonHispanic
American
Indian and
Alaskan
Native
Source: Health, United States, 2006, Table 135.
Asian
Hispanic or
Latino
Percentage With Access
Problems
35
30
All Persons
25
Medicare
20
Private
15
Medicaid
10
Uninsured
5
0
Percent with no usual source of care
Percent of Children under 18 with
No Usual Source of Care
by Insurance Type, 2006-2007
40
35
33.6
30
25
20
15
10
5
5.2
3
Medicaid
Private
0
Uninsured
Source: Health United States, 2009, Table 75
Vaccinations among Children 19-35
months old by Poverty Status and Race, 2007
Percent receiving combined series
85
80
75
Poor
70
Non-Poor
65
60
White, non-Hispanic
Black, non-Hispanic
Source: Health, United States, 2009, Table 82
Hispanic
Proportion of Live Births with Late* or No
Prenatal Care, by Race and Ethnicity of
Mother, 2006
9
8
Percent of Live Births
8.1
7
6
5.7
5
5
4
3
3.2
3.1
2
1
0
White
Black
American Indian or
Alaskan Native
Asian or Pacific
Islander
Hispanic Origin
*third trimester
Source: Health, United States, 2009, Table 7 (37 states, DC and NYC)
Children under 6 with no physician contacts
within last year, by race, and Hispanic origin,
and poverty status, 2005-2006
Percent without a visit
12
10
8
Poor
Near Poor
Nonpoor
6
4
2
0
All race
White, non- Black, nonHispanic Hispanic*
Hispanic
AVERAGE all children under 6 without a health care visit in 2005-6 – 6.1%
* Estimates are for 2004/2005 (data not available for 2005-2006)
Source: Health, United States, 2008, Table 82
Persons with Hospital Stay in the Past Year*,
By Poverty and Insurance Status, 2007
12
Percent of persons
10
8
Insured
6
Uninsured
>12 mths
4
2
0
Poor
Near Poor
Non-Poor
Poverty and Insurance Status
* Persons under 65 years of age
Source: Health, United States, 2009, Table 98
Discharges per 1,000 population
Avoidable Hospitalizations - Adults 18-64 yrs
old by household income* and race, 1989-1991
20
18
16
14
12
10
8
6
4
2
0
<$20,000
$20,000-$29,999
$30,000-$39,999
$40,000+
All races
White
* Median household income in Zip code of residence
Source: Health, United States, 1998, Figure 48
Black
Discharges per 1,000 population
Asthma Hospitalizations - Children 1-14 yrs
of age by household income* and race, 19891991
8
7
6
5
<$20,000
$20,000-$29,999
$30,000-$39,999
$40,000+
4
3
2
1
0
All races
White
*Median household income in Zip code of residence
Source: Health, United States, 1998, Figure 24
Black
UNEQUAL TREATMENT
Black/White and SES
Differences When Patients Have
Same Diagnosis
“The health system is less
responsive to black patients then
to white patients.”
(Epstein and Ayanian, 2001)
The same is true for low vs. high
income patients.
Institute of Medicine Report
Unequal Treatment
“Racial and ethnic minorities
tend to receive a lower quality of
healthcare than non-minorities,
even when access-related factors,
such as patients’ insurance status
and income, are controlled.”
IOM, Unequal Treatment, 2002
Studies have shown this to be
true for patients with:
• Heart attacks and heart disease (PTCA and
CABGS)
• Peripheral vascular disease of the lower
extremities (amputation vs. revascularization)
• ESRD (transplants vs. dialysis)
• Small-cell carcinoma of the lungs
• Psychiatric problems
• Many more diagnoses
Racial Disparities In Early Stage Lung Cancer
Treatment
80
70
Percent or rate
60
50
34.9
40
26.4
Rate of Surgery
5yr Survival Rate
30
20
10
0
White
Black
Source: Bach et. al,. Racial differences in the treatment of early-stage lung cancer. N
Engl J Med. 1999 Oct 14;341(16):1198-205.
Racial Disparities In Rehabilitation Services
after Hip Fracture (odds ratio)
1.4
1.2
Ratio
1
0.8
White
Black
0.6
0.4
0.2
0
Acute Rehab
SNU Rehab
No Rehab
Source: Harada et. al,. Patterns of rehabilitation utilization after hip fracture in acute
hospitals and skilled nursing facilities. Med Care. 2000 Nov;38(11):1119-30.
Will the Passage of Health
(Insurance) Reform, which will
provide insurance coverage to 32
Million more Americans,
eliminate Health Disparities?