Racial, Ethnic and
Socioeconomic Health
Disparities in the US
Richard Lichtenstein Ph.D., MPH
University of Michigan
School of Public Health
June 2007
Fair or Poor Health among Adults
18 years and older by family income, race,
and Hispanic origin, 2004
Poor
Near Poor
Non-Poor
30
Percent
25
20
15
10
5
0
White, non-Hispanic
Source: Health, United States, 2006 Table 60
Black, non-Hispanic
Hispanic
Why are Poverty and
Race/Ethnicity Related to
Health?
What Racial/Ethnic Group
Accounts for the Most Poor
People in the US?
Number of Persons Below Poverty Level By
Race, 2004
In Thousands
40000
30000
20000
10000
0
All races
White
Black
Source: Health, United States, 2006, Table 3
Asian
Hispanic
Percent of Persons Below Poverty Level By
Race, 2003
Percent below poverty
25%
20%
15%
10%
5%
0%
All races
White
Black
Asian
Source: Health, United States, 2006, Table 3
Hispanic or Latino
Figure 2.6
Percent of Persons with Incomes Below
Poverty Level by Age
City of Detroit
Detroit PMSA*
Wayne County
Michigan
35
30
25
20
15
10
5
0
r
de
n
U
5
-1 7
15
18
an
r
ve
o
d
65
Source: U.S. Bureau of the Census, Census 2000 Supplementary Survey
* Primary Metropolitan Statistical Area
an
r
ve
o
d
What is Race?
What is Race?
• “Race is a social construct, a social
classification based on phenotype, that
governs the distribution of risks and
opportunities in our race-conscious
society.”
• Race is not a biological determinant.
Camara Phyllis Jones
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
What is Race?
Phenotypically and/or geographically
distinctive sub-specific group, composed of
individuals inhabiting a defined geographical
and/or ecological region, and possessing
characteristic phenotypic and gene frequencies
that distinguish it from other such groups.
The number of racial groups that one
wishes to recognize within a species is
usually arbitrary but suitable for the
purposes under investigation.
Dictionary of Genetics (1990)
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
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).
Some Data on Detroit and
Some Neighborhoods in
Detroit
Population by Race
City of Detroit Health Dept. and Michigan Residents, 2003
City of Detroit Health Dept.
Michigan
Black
83%
White
82%
Other
5%
White
12%
Black
14%
Other
4%
Source: U.S. Bureau of the Census, Census 2000 Supplementary Survey:http://www.census.gov/acs/
Demographic Characteristics of
the Eastside of Detroit
Table 1: Sociodemographic Characteristics of
Eastside and Central Detroit in Comparison to City of
Detroit and the National Average
Characteristic
48213
48201/08/16/23
City of Detroit
Median
Income
% Below
Poverty
% High school
graduates
% AfricanAmerican
% Single
parent
household
$24,633
$18,045
$29,526
National
Average*
$37,005
33.63%
40.74%
28.32%
12.4%
60.43%
64.25%
67.62%
80.4%
96.14%
73.03%
80.54%
12.3%
40.11%
38.46%
32.97%
16.4%
*2000 Census, www.census.gov
Detroit 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
Age Adjusted
Mortality Rates (per
100,000)
Heart disease
Homicide
HIV/AIDS
Cancer (all types)
Diabetes Mellitus
Infant Mortality**
48213
City of Detroit
National Average*
405.02
49.34
24.92
242.28
35.12
17.94
411.34
41.03
14.16
239.89
34.0
14.77
240.8
6.1
4.9
193.5
25.4
7.0
Detroit data from www.chimart.org, 1999-2001 data
*2002 Data from Health, United States, 2005 Table 29
**Infant deaths/1000 live births, Health United States Table 25
Life Expectancy at Birth
by Race and Sex, 1970-2003
85
80
75
White
Male
70
White
Female
65
60
Black
Male
Black
Female
Source: Health, United States, 2005, Table 27,
http://www.cdc.gov/nchs/data/hus/hus05.pdf#summary
2002
2000
1998
1996
1994
1992
1990
1980
1970
55
Why Do Blacks Have a Shorter
Life Expectancy Than Whites?
Age-Adjusted Death Rates
Due to All Causes,
by Race and Hispanic Origin, 2003
White
Am. Indian or Alaskan
Hispanic
Age-Adjusted Death Rate
1200
1000
800
600
400
200
0
Source: Health, United States, 2005, Table 29
http://www.cdc.gov/nchs/data/hus/hus05.pdf#summary
Black
Asian/Pacific Islander
Years of Potential Life Lost
due to Ischemic Heart Disease,
by race and Hispanic origin, 2003
Years lost*
White
Am. Indian or Alaskan
Hispanic
Black
Asian/Pacific Islander
1200
1000
800
600
400
200
0
2003
Source: Health, United States, 2005, Table 30
http://www.cdc.gov/nchs/data/hus/hus05.pdf#summary
* Age-adjusted years lost before age 75 per
100,000 population under 75 years of age.
Years of Potential Life Lost
due to Cerebrovascular Diseases,
by race and Hispanic origin, 2003
White
Am. Indian or Alaskan
Hispanic
Black
Asian/Pacific Islander
Years lost*
600
400
200
0
3
200
Source: Health, United States, 2005, Table 30
http://www.cdc.gov/nchs/data/hus/hus05.pdf#summary
* Age-adjusted years lost before age 75 per
100,000 population under 75 years of age.
Years of Potential Life Lost
due to Breast Cancer,
Females by race and Hispanic origin, 2003
White
Am. Indian or Alaskan
Hispanic
Black
Asian/Pacific Islander
Years lost*
600
450
300
150
0
2003
Source: Health, United States, 2005, Table 30
http://www.cdc.gov/nchs/data/hus/hus05.pdf#summary
* Age-adjusted years lost before age 75 per
100,000 population under 75 years of age.
Years of Potential Life Lost
due to Prostate Cancer,
Males by race and Hispanic origin, 2003
White
Am. Indian or Alaskan
Hispanic
Black
Asian/Pacific Islander
Years lost*
160
120
80
40
0
3
200
Source: Health, United States, 2005, Table 30
http://www.cdc.gov/nchs/data/hus/hus05.pdf#summary
* 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, 2003
White
Am. Indian or Alaskan
Hispanic
Black
Asian/Pacific Islander
Years lost*
400
300
200
100
0
Source: Health, United States, 2005, Table 30
http://www.cdc.gov/nchs/data/hus/hus05.pdf#summary
03
0
2
* Age-adjusted years lost before age 75 per
100,000 population under 75 years of age.
Years of Potential Life Lost
due to HIV Infection,
by race and Hispanic origin, 2003
White
Am. Indian or Alaskan
Hispanic
Black
Asian/Pacific Islander
Years lost*
900
600
300
0
Source: Health, United States, 2005, Table 30
http://www.cdc.gov/nchs/data/hus/hus05.pdf#summary
3
200
* 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, 2003
White
Am. Indian or Alaskan
Hispanic
Black
Asian/Pacific Islander
Years lost*
1000
800
600
400
200
0
Source: Health, United States, 2005, Table 30
http://www.cdc.gov/nchs/data/hus/hus05.pdf#summary
3
200
* Age-adjusted years lost before age 75 per
100,000 population under 75 years of age.
5 Year Relative Survival Rates
for Breast Cancer
100
90
White Female
80
70
Black Female
60
50
1974-79
1980-82
1983-85
1986-88
1989-91
1992-94
19962002
Source: Health, United States, 2006, Table 54: http://www.cdc.gov/nchs/data/hus/hus06.pdf#summary
40
All races
White
Black
30
20
10
0
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
Deaths per 1,000 Live Births
Infant Mortality Rates by Race*
United States, 1970-2003
Source: Health, United States, 2006, Table 22
*Race of mother
Figure 24. Infant mortality rates by detailed race and Hispanic origin of mother: United States,
1999-2001
White, not Hispanic
Black, not Hispanic
Hispanic (total)
Puerto Rican
Other Hispanic
Mexican
Central and South American
Cuban
Asian or Pacific Islander (total)
Hawaiian
Filipino
Other Asian or Pacific Islander
Japanese
Chinese
American Indian or Alaska
Native
0
2
4
6
8
10
12
14
16
Infant per 1,000 live births
NOTES: 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.
SOURCE: Centers for Disease Control and Prevention, National
Center for Health Statistics, National Linked Birth/Infant Death
Data Sets.
Centers for Disease Control and Prevention, National Center for Health Statistics. Health, United States, 2004
IMR for US in 2004 was 6.37
NOTE: The US placed 180 out of
221 countries (higher is better)
Source: CIA World Factbook:
https://www.cia.gov/cia/publications/factbook/geos/us.html#People (accessed May 06,
2007 )
Infant Mortality Rate* by Country
18
Hong Kong
Infant Mortality Rate
16
14
Japan
U.S.
12
France
Canada
10
Cuba
8
US
6
Costa Rica
4
Russia
2
Romania
0
2003
*IMR: Deaths of infants under 1 year per 1,000 live births
Source: Health, United States, 2006, Table 25
International Rankings for Infant Mortality
1960 and 2002
1960
2002
26
1
1
2
21
3
6
4
Japan
18
4
Spain
28
6
Norway
3
7
Austria
24
8
France
15
8
4
Germany
Hong Kong
1960
2002
Scotland
12
22
Canada
14
23
Israel
19
23
Greece
25
25
New Zealnd
10
26
Cuba
23
27
U.S.
11
28
Hungary
31
29
10
Poland
32
30
22
11
Slovakia
16
31
Denmark
8
12
Chile
36
32
Switzerland
7
13
Puerto Rico
27
33
Italy
29
14
Costa Rica
33
34
N. Ireland
13
14
Russian F.
Belgium
20
16
Australia
5
17
Netherlands
2
17
Portugal
35
17
Ireland
17
20
9
21
Sweden
Singapore
Finland
Czech Republic
England/Wales
n/a
35
Bulgaria
30
36
Romania
34
37
IMR - International Rankings 2007
Country
Angola
Sierra Leone
Afghanistan
Liberia
Niger
United States
Norway
Finland
France
Iceland
Hong Kong
Japan
Sweden
Singapore
Infant mortality rate
(deaths/1,000 live births)
Rank
184.44
158.27
157.43
149.73
116.83
1
2
3
4
5
6.37
180
3.64
3.52
3.41
3.27
2.94
2.80
2.76
2.30
214
215
216
217
218
219
220
221
Source: CIA – The World Factbook:
https://www.cia.gov/cia/publications/factbook/rankorder/2091rank.html (accessed May 06, 2007)
Infant Mortality by Race of Mother,
2005
City of Detroit
Wayne County*
Michigan
*=excludes Detroit
Deaths per 1,000
live births
25
20
15
10
5
0
Total
White
Black
Source: Division for Vital Records and Health Statistics, Michigan Department of Community Health, 2007
http://www.mdch.state.mi.us/pha/osr/InDxMain/Infsum05.asp
Infant Mortality Rates by mother’s education, race,
and Hispanic origin, 2000-2003
White, non-Hispanic
Hispanic
Asian or Pacific Islander
15
Black, non-Hispanic
American Indian or Alaska Native
IMR
12
9
6
3
0
Less than 12 years
12 years
Years of Education
Source: Health, United States, 2006, Table 20
13+ years
Activity Limitation among Adults
by family income, race, and Hispanic
origin, 2004
Poor
Near poor
Nonpoor
Percent with limitation
30
25
20
15
10
5
0
All races
White, nonHispanic
Source: Health, United States, 2006, Table 58
Black, nonHispanic
Hispanic
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
Source: Health, United States, 2006, Table 135.
American
Indian and
Alaskan
Native
Asian
Hispanic or
Latino
Vaccinations among Children 19-35
months old by Poverty Status and Race, 2004
Percent receiving
combined series
85
80
75
Poor
Non-Poor
70
65
60
All races White, non- Black, non- Hispanic
Hispanic Hispanic
Source: Health, United States, 2006, Table 81.
Percent with no usual source of care
Percent of Children under 18 with
no Usual Source of Care
by insurance type, 2003-2004
35
30
28.8
25
20
15
10
4.6
5
2.3
0
Uninsured
Source: Health United States, 2006, Table 76.
Medicaid
Private
Children under 6 with no physician contacts
within last year, by Race and Poverty Status, 20032004
Percent without a visit
12
10
8
6
Poor
Near Poor
Nonpoor
4
2
0
All races White, non- Black, nonHispanic
Hispanic
Source: Health, United States, 2006, Table 79
Hispanic
Asthma Hospitalizations - Children 1-14 yrs
of age by household income* and race, 19891991
8
Discharges per 1,000
population
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, Table 21
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
76.6
70
64
Percent
60
50
40
34.9
26.4
30
Rate of Surgery
5yr Survival Rate
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.
Ratio
Racial Disparities In Re-Perfusion Therapy
after Acute Myocardial Infarction (odds ratio)
1
0.9
0.8
0.7
0.6
0.5
0.4
0.3
0.2
0.1
0
White
Black
CABG
PTCA
Thrombolytics
Source: Weitzman et. al,. Gender, racial, and geographic differences in the performance of cardiac
diagnostic and therapeutic procedures for hospitalized acute myocardial infarction in four states. Am J
Cardiol. 1997 Mar 15;79(6):722-6.
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.
Inadequate Analgesic
Administration
• Black patients with isolated long-bone fractures
were less likely to receive analgesics than whites,
despite similar pain complaints, in an urban ED in
Atlanta.
– Study controlled for multiple confounders, including
time since injury, total time in ED, need for fracture
reduction.
• Author previously found that Hispanic ethnicity
was a risk factor for inadequate analgesia.
Source: Todd et al. (2000) “Ethnicity and Analgesic Practice” Annals of
Emergency Medicine, vol. 35(1), pp.11-16.
Other Barriers to Receipt
of Care
Percentage With Access
Problems
35
30
All Persons
25
Medicare
20
Private
15
Medicaid
10
Uninsured
5
0
The Uninsured by Race and Income
Non-Elderly, Calendar Year 2003*
Percent uninsured
<100%poverty
100-200%
>400%
40
35
30
25
20
15
10
5
0
All Races
White
Black
Asian/Pac
Am
Hispanic
Ind/Alask
Source: ERIU tabulation of 2004 CPS data. *Data may represent more of a “point in time”
estimate than a true full-year estimate.
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.