Transcript Figure 3.1 Age-Adjusted Mortality Rates City of Detroit
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 25 20 15 10 5 0 White, non-Hispanic Black, non-Hispanic Hispanic
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
40000 30000 20000 10000 0 All races White Black Asian Hispanic
Source: Health, United States, 2006, Table 3
Percent of Persons Below Poverty Level By Race, 2003
25% 20% 15% 10% 5% 0% All races White Black Asian Hispanic or Latino
Source: Health, United States, 2006, Table 3
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 Un de r 5 15 -17 18 an d o ve r
Source: U.S. Bureau of the Census, Census 2000 Supplementary Survey
65 an d o ve r
* 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.” 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 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 Race City of Detroit Health Dept. and Michigan Residents, 2003 City of Detroit Health Dept.
Black 83% White 82%
Michigan
Other 5% Black 14% Other 4% White 12%
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 National Average*
$37,005
Median Income % Below Poverty
$24,633 33.63% $18,045 40.74%
% High school graduates % African American % Single
60.43% 96.14% 40.11% 64.25% 73.03% 38.46%
parent household
*2000 Census, www.census.gov
$29,526 28.32% 67.62% 80.54% 32.97% Detroit data from www.chimart.org
, 1999-2001 data 12.4% 80.4% 12.3% 16.4%
Table II: Health Status Characteristics of the Eastside in Comparison to the City of Detroit and the U.S. Population
City of Detroit National Average* Age Adjusted Mortality Rates (per 100,000) Heart disease Homicide HIV/AIDS Cancer (all types) Diabetes Mellitus Infant Mortality** 48213
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
85 80 75 70 65 60 55
Life Expectancy at Birth by Race and Sex, 1970-2003
White Male White Female Black Male Black Female
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 Rates Due to All Causes, by Race and Hispanic Origin, 2003
White Am. Indian or Alaskan Hispanic 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
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 600 400 200 0 2003
Source: Health, United States, 2005, Table 30 http://www.cdc.gov/nchs/data/hus/hus05.pdf#summary
Black Asian/Pacific Islander
* 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 600 450 300 150 0
Source: Health, United States, 2005, Table 30 http://www.cdc.gov/nchs/data/hus/hus05.pdf#summary
2003
* 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 160 120 80 40 0
Source: Health, United States, 2005, Table 30 http://www.cdc.gov/nchs/data/hus/hus05.pdf#summary
2003
* 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 400 300 200 100 0
Source: Health, United States, 2005, Table 30 http://www.cdc.gov/nchs/data/hus/hus05.pdf#summary
2003 Black Asian/Pacific Islander
* 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 900 Black Asian/Pacific Islander 600 300 0
Source: Health, United States, 2005, Table 30 http://www.cdc.gov/nchs/data/hus/hus05.pdf#summary
2003
* 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 1000 800 600 400 200 0
Source: Health, United States, 2005, Table 30 http://www.cdc.gov/nchs/data/hus/hus05.pdf#summary
2003
* 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 1996 2002
Source: Health, United States, 2006, Table 54: http://www.cdc.gov/nchs/data/hus/hus06.pdf#summary
30 20 10 40
Infant Mortality Rates by Race* United States, 1970-2003
All races White Black 0
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 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.
10 12 14 16 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 )
6 4 2 0 18 16 14 12 10 8
Infant Mortality Rate* by Country
U.S.
Hong Kong Japan France Canada Cuba US Costa Rica Russia Romania 2003
*IMR: Deaths of infants under 1 year per 1,000 live births Source: Health, United States, 2006, Table 25
Hong Kong Sweden Singapore Finland Japan Spain Norway Austria France Czech Republic Germany Denmark Switzerland Italy N. Ireland Belgium Australia Netherlands Portugal Ireland England/Wales International Rankings for Infant Mortality 1960 and 2002
1960
26
1
21 6 18 28 3 24 15 4 22 8 7 29 13 20 5 2 35 17 9
2002 1
2 3 4 4 6 7 8 8 10 11 12 13 14 14 16 17 17 17 20 21 Scotland Canada Israel Greece New Zealnd Cuba
U.S.
Hungary Poland Slovakia Chile Puerto Rico Costa Rica Russian F.
Bulgaria Romania
1960
12 14 19 25 10 23
36
27 n/a 33 30
11
31 32 16 34
2002
22 23 23 25 26 27
28
29 30 31 32 33 34 35 36
37
IMR - International Rankings 2007
Country Infant mortality rate (deaths/1,000 live births) Rank Angola Sierra Leone Afghanistan Liberia Niger United States Norway Finland France Iceland Hong Kong Japan Sweden Singapore 184.44 158.27 157.43 149.73
116.83
6.37
3.64
3.52 3.41
3.27
2.94
2.80
2.76
2.30
1 2 3 4 5 180 214 215 216 217 218 219 220 221 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*
*=excludes Detroit
Michigan 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
12 9 6 3 0 Less than 12 years 12 years
Source: Health, United States, 2006, Table 20
Years of Education 13+ years
Activity Limitation among Adults
by family income, race, and Hispanic origin, 2004
Poor Near poor Nonpoor 30 25 20 15 10 5 0 All races White, non Hispanic Black, non Hispanic
Source: Health, United States, 2006, Table 58
Hispanic
No Health Insurance Coverage among persons under 65, by race and Hispanic origin, 2004
20 15 10 5 0 40 35 30 25 White, non Hispanic Black, non Hispanic American Indian and Alaskan Native Asian Hispanic or Latino
Source: Health, United States, 2006, Table 135.
Vaccinations among Children 19-35 months old by Poverty Status and Race, 2004
85 80 75 70 65 60 All races White, non Hispanic Black, non Hispanic Hispanic
Source: Health, United States, 2006, Table 81.
Poor Non-Poor
Percent of Children under 18 with no Usual Source of Care by insurance type, 2003-2004 35 30 25 20 15 10 5 0 28.8
4.6
Uninsured
Source: Health United States, 2006, Table 76.
Medicaid 2.3
Private
Children under 6 with no physician contacts within last year, by Race and Poverty Status, 2003 2004
12 10 8 6 4 2 0
Poor Near Poor Nonpoor
All races White, non Hispanic Black, non Hispanic Hispanic
Source: Health, United States, 2006, Table 79
Asthma Hospitalizations - Children 1-14 yrs of age by household income* and race, 1989 1991
1 0 3 2 5 4 8 7 6
<$20,000 $20,000-$29,999 $30,000-$39,999 $40,000+
All races White Black
*Median household income in Zip code of residence Source: Health, United States, 1998, Table 21
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. 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
80 70 60 50 40 30 20 10 0 34.9
64 26.4
Rate of Surgery 5yr Survival Rate 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 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)
0.6
0.4
0.2
0 1.4
1.2
1 0.8
Acute Rehab White Black 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
35 30 25 20 15 10 5 0
Percentage With Access Problems
All Persons Medicare Private Medicaid Uninsured
The Uninsured by Race and Income Non-Elderly, Calendar Year 2003*
<100%poverty 40 35 30 25 20 15 10 5 0 All Races White 100-200% >400% Black Asian/Pac Am Ind/Alask Hispanic
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.