Racial, Ethnic and Socioeconomic Health Disparities in the US

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 Adults18 years and older by family income, race,

and Hispanic origin, 2004

0

5

10

15

20

25

30

Per

cent

White, non-Hispanic Black, non-Hispanic Hispanic

Poor Near Poor Non-Poor

Source: Health, United States, 2006 Table 60

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

0

10000

20000

30000

40000

All races White Black Asian Hispanic

Source: Health, United States, 2006, Table 3

In T

hou

sand

s

Percent of Persons Below Poverty Level By Race, 2003

0%

5%

10%

15%

20%

25%

All races White Black Asian Hispanic or Latino


Per

cen

t b

elow

pov

erty

Figure 2.6Percent of Persons with Incomes Below

Poverty Level by Age

0

5

10

15

20

25

30

35

City of Detroit Wayne CountyDetroit PMSA* Michigan

Source: U.S. Bureau of the Census, Census 2000 Supplementary Survey* Primary Metropolitan Statistical Area

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.”


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.”


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 well-being—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 RaceCity of Detroit Health Dept. and Michigan Residents, 2003

Black83%

White12%

Other5%

Other4%

White82%

Black14%

City of Detroit Health Dept. Michigan

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 AverageCharacteristic 48213 48201/08/16/23 City of Detroit National

Average* Median Income

$24,633 $18,045 $29,526 $37,005

% Below Poverty

33.63% 40.74% 28.32% 12.4%

% High school graduates

60.43%

64.25% 67.62% 80.4%

% African-American

96.14% 73.03% 80.54% 12.3%

% Single parent household

40.11% 38.46% 32.97% 16.4%

*2000 Census, www.census.govDetroit 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)

48213 City of Detroit National Average*

Heart disease 405.02 411.34 240.8 Homicide 49.34 41.03 6.1 HIV/AIDS 24.92 14.16 4.9 Cancer (all types) 242.28 239.89 193.5 Diabetes Mellitus 35.12 34.0 25.4 Infant Mortality** 17.94 14.77 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

55

60

65

70

75

80

85

1970

1980

1990

1992

1994

1996

1998

2000

2002

WhiteMale

WhiteFemale

BlackMale

BlackFemale

Source: Health, United States, 2005, Table 27, http://www.cdc.gov/nchs/data/hus/hus05.pdf#summary

Why Do Blacks Have a Shorter Life Expectancy Than Whites?

Age-Adjusted Death RatesDue to All Causes,

by Race and Hispanic Origin, 2003

0

200

400

600

800

1000

1200

Age

-Ad

just

ed D

eath

Rat

e

White BlackAm. Indian or Alaskan Asian/Pacific IslanderHispanic

Source: Health, United States, 2005, Table 29http://www.cdc.gov/nchs/data/hus/hus05.pdf#summary

Years of Potential Life Lostdue to Ischemic Heart Disease,

by race and Hispanic origin, 2003

0200400600800

10001200

Yea

rs l

ost*

2003


Source: Health, United States, 2005, Table 30http://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 Lostdue to Cerebrovascular Diseases,by race and Hispanic origin, 2003

0

200

400

600

Yea

rs lo

st*



http://www.cdc.gov/nchs/data/hus/hus05.pdf#summary


Years of Potential Life Lostdue to Breast Cancer,

Females by race and Hispanic origin, 2003

0

150

300

450

600

Yea

rs lo

st*

2003



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 Lostdue to Prostate Cancer,

Males by race and Hispanic origin, 2003

0

40

80

120

160

Yea

rs lo

st*



http://www.cdc.gov/nchs/data/hus/hus05.pdf#summary


Years of Potential Life Lostdue to Diabetes Mellitus,


0

100

200

300

400

Yea

rs lo

st*




Years of Potential Life Lostdue to HIV Infection,


0

300

600

900

Yea

rs lo

st*



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 Lostdue to Homicide,


0

200

400

600

800

1000

Yea

rs lo

st*




5 Year Relative Survival Rates for Breast Cancer

50

60

70

80

90

100

1974-79 1980-82 1983-85 1986-88 1989-91 1992-94 1996-2002

White Female

Black Female

Per

cen

t of

Pat

ien

ts (

%)

Source: Health, United States, 2006, Table 54: http://www.cdc.gov/nchs/data/hus/hus06.pdf#summary

Infant Mortality Rates by Race*United States, 1970-2003

0

10

20

30

40

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

All races White Black


Dea

ths

per

1,0

00 L

ive

Bir

ths

*Race of mother

0 2 4 6 8 10 12 14 16

Black, not Hispanic

Hispanic (total)

Puerto Rican

White, not Hispanic

Cuban

Mexican

Japanese

Chinese

Hawaiian

Central and South American

Figure 24. Infant mortality rates by detailed race and Hispanic origin of mother: United States, 1999-2001

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.

Infant per 1,000 live births

Other Hispanic

Filipino

Centers for Disease Control and Prevention, National Center for Health Statistics. Health, United States, 2004

Asian or Pacific Islander (total)

Other Asian or Pacific Islander

American Indian or Alaska Native

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

0

2

4

6

8

10

12

14

16

18

Infa

nt M

orta

lity

Rat

e

2003

Hong Kong

Japan

France

Canada

Cuba

US

Costa Rica

Russia

Romania


*IMR: Deaths of infants under 1 year per 1,000 live births

U.S.

International Rankings for Infant Mortality1960 and 2002

1960 2002

Hong Kong 26 1

Sweden 1 2

Singapore 21 3

Finland 6 4

Japan 18 4

Spain 28 6

Norway 3 7

Austria 24 8

France 15 8

Czech Republic 4 10

Germany 22 11

Denmark 8 12

Switzerland 7 13

Italy 29 14

N. Ireland 13 14

Belgium 20 16

Australia 5 17

Netherlands 2 17

Portugal 35 17

Ireland 17 20

England/Wales 9 21

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

Poland 32 30

Slovakia 16 31

Chile 36 32

Puerto Rico 27 33

Costa Rica 33 34

Russian F. n/a 35

Bulgaria 30 36

Romania 34 37

1960 2002

IMR - International Rankings 2007

Source: CIA – The World Factbook: https://www.cia.gov/cia/publications/factbook/rankorder/2091rank.html (accessed May 06, 2007)

Country Infant mortality rate Rank (deaths/1,000 live births)

Angola 184.44 1Sierra Leone 158.27 2Afghanistan 157.43 3Liberia 149.73 4 Niger 116.83 5---United States 6.37 180---Norway 3.64 214 Finland 3.52 215France 3.41 216 Iceland 3.27 217 Hong Kong 2.94 218 Japan 2.80 219 Sweden 2.76 220 Singapore 2.30 221

Infant Mortality by Race of Mother, 2005

0

5

10

15

20

25

Dea

ths

per

1,0

00

live

bir

ths

Total White Black

City of Detroit Wayne County* Michigan

Source: Division for Vital Records and Health Statistics, Michigan Department of Community Health, 2007http://www.mdch.state.mi.us/pha/osr/InDxMain/Infsum05.asp

*=excludes Detroit

Infant Mortality Rates by mother’s education, race, and Hispanic origin, 2000-2003

0

3

6

9

12

15

IMR

Less than 12 years 12 years 13+ years

Years of Education

White, non-Hispanic Black, non-HispanicHispanic American Indian or Alaska NativeAsian or Pacific Islander


Activity Limitation among Adults by family income, race, and Hispanic

origin, 2004

0

5

10

15

20

25

30

Per

cent

wit

h li

mit

atio

n

All races White, non-Hispanic

Black, non-Hispanic

Hispanic

Poor Near poor Nonpoor


No Health Insurance Coverage among persons under 65, by race and Hispanic origin, 2004

05

10152025303540

White, non-Hispanic

Black, non-Hispanic

AmericanIndian and

AlaskanNative

Asian Hispanic orLatino

Per

cent

uni

nsur

ed

Source: Health, United States, 2006, Table 135.

Vaccinations among Children 19-35 months old by Poverty Status and Race, 2004

60

65

70

75

80

85

Per

cent

rec

eivi

ng

com

bine

d se

ries


Black, non-Hispanic

Hispanic

Poor

Non-Poor

Source: Health, United States, 2006, Table 81.

Percent of Children under 18 with no Usual Source of Care

by insurance type, 2003-2004

28.8

4.62.3

0

5

10

15

20

25

30

35

Uninsured Medicaid Private

Per

cen

t w

ith

no

usu

al s

ourc

e of

car

e

Source: Health United States, 2006, Table 76.

Children under 6 with no physician contactswithin last year, by Race and Poverty Status, 2003-

2004

0

2

4

6

8

10

12

Per

cent

wit

hout

a v

isit


Black, non-Hispanic

Hispanic

Poor

Near Poor

Nonpoor


Asthma Hospitalizations - Children 1-14 yrs of age by household income* and race, 1989-

1991

0

1

2

3

4

5

6

7

8

Dis

char

ges

per

1,00

0 po

pula

tion

All races White Black

<$20,000

$20,000-$29,999

$30,000-$39,999

$40,000+


*Median household income in Zip code of residence

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 ReportUnequal 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, IOM, Unequal Treatment, 2002Unequal 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. re-vascularization)

• ESRD (transplants vs. dialysis)• Small-cell carcinoma of the lungs• Psychiatric problems• Many more diagnoses

Racial Disparities In Early Stage Lung Cancer Treatment

76.6

34.9

64

26.4

0

10

20

30

40

50

60

70

80

Per

cen

t

White Black

Rate of Surgery

5yr Survival Rate

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 Re-Perfusion Therapy after Acute Myocardial Infarction (odds ratio)

0

0.10.20.30.40.50.60.7

0.80.9

1

Rat

io

CABG PTCA Thrombolytics

White

Black

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)

0

0.2

0.4

0.6

0.8

1

1.2

1.4

Rat

io

Acute Rehab SNU Rehab No Rehab

White

Black

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 ofSource: Todd et al. (2000) “Ethnicity and Analgesic Practice” Annals ofEmergency Medicine, vol. 35(1), pp.11-16.Emergency Medicine, vol. 35(1), pp.11-16.

Other Barriers to Receipt of Care

Percentage With Access Problems

0

5

10

15

20

25

30

35

All Persons

Medicare

Private

Medicaid

Uninsured

The Uninsured by Race and IncomeNon-Elderly, Calendar Year 2003*

0

5

10

15

20

25

30

35

40

Per

cent

uni

nsur

ed

All Races White Black Asian/Pac AmInd/Alask

Hispanic

<100%poverty 100-200% >400%

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 DentistPr. George's Boy Dies After Bacteria From Tooth Spread to BrainBy Mary OttoWashington Post Staff WriterWednesday, 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.

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Racial, Ethnic and Socioeconomic Health Disparities in the US